Every finding on record at Watsonville Nursing Center

Based on interview and record review, the facility failed to manage pain for four of 18 residents (4, 6, 46, and 47) when license nurses did not administer pain medication according to the pain level ordered by the physician. This failure had the potential for the residents to experience avoidable pain and could negatively affect their quality of life.Findings:1. Review of Resident 6's admission Record indicated she was admitted to the facility on [DATE] with pain in right hip diagnosis.Review of Resident 6's physician order, dated 7/5/23, indicated she had an order for acetaminophen (a drug that reduces pain and fever) 325 milligrams (mg, a metric unit of mass) 2 tablets every 4 hours as needed for mild pain level 1-3.Review of Resident 6's Medication Administration Record (MAR), from 10/2025 to 12/2025, indicated two tablets of acetaminophen 325 mg were administered to Resident 6 when her pain level was higher than 3 on 10/5/25, 10/18/25, 11/8/25, 11/24/25, and 12/7/25.During an interview with the director of nursing (DON) on 1/9/26, at 12:33 p.m., he reviewed Resident 6's 10/2025 - 12/2025 MARs and confirmed that Resident 6 was administered with two tablets of acetaminophen 325 mg when her pain level was higher than 3 on 10/5/25, 10/18/25, 11/8/25, 11/24/25, and 12/7/25. 2. Review of Resident 4's admission Record indicated he was admitted to the facility on [DATE] with phantom limb syndrome with pain (the feeling of pain or discomfort in a limb that has been amputated) diagnosis.Review of Resident 4's physician order, dated 10/20/25, indicated he had an order for acetaminophen 500 mg every 6 hours as needed for mild pain level 1-3.Review of Resident 4's MARs, 11/2025 and 12/2025, indicated acetaminophen 500 mg was administered to Resident 4 when his pain level was higher than 3 on 11/6/25 and 12/20/25.During an interview with the DON on 1/9/26, at 12:41 p.m., he reviewed Resident 4's 11/2025 and 12/2025 MARs and confirmed that Resident 4 was administered 500 mg acetaminophen when his pain level was higher than 3 on 11/6/25 and 12/20/25. 3. Review of Resident 46's admission Record indicated she was admitted to the facility on [DATE] with chronic pain diagnosis.Review of Resident 46's physician order, dated 1/1/26, indicated she had an order for acetaminophen 500 mg every 4 hours as needed for mild pain level 1-3.Review of Resident 46's 1/2026 MAR indicated acetaminophen 500 mg was administered to Resident 46 when her pain level was higher than 3 on 1/2/26.During an interview with the DON on 1/9/26, at 12:42 p.m., he reviewed Resident 46's 1/2026 MAR and confirmed that Resident 46 was administered 500 mg acetaminophen when her pain level was higher than 3 on 1/2/26. 4. Review of Resident 47's admission Record indicated he was admitted to the facility on [DATE] with left hip osteoarthritis (a degenerative joint disease where cartilage wears down, causing joint pain, stiffness, and swelling) diagnosis.Review of Resident 47's physician order, dated 5/23/25, indicated he had an order for acetaminophen 500 mg every 6 hours as needed for mild pain level 1-3.Review of Resident 47's MARs, from 9/2025 to 1/2026, indicated acetaminophen 500 mg was administered to Resident 47 when his pain level was higher than 3 on 9/23/25, 9/24/25, 10/3/25, 10/4/25, 10/18/25, 10/24/25, 10/30/25, 10/31/25, 11/1/25, 11/3/25, 11/7/25, 11/8/25, 11/9/25, 11/14/25, 11/15/25, 12/17/25, 12/26/25, 12/30/25, 1/2/26, and 1/3/26.During an interview with the DON on 1/9/26, at 12:45 p.m., he reviewed Resident 47's 9/2025 - 1/2026 MARs and confirmed that Resident 47 was administered 500 mg acetaminophen when his pain level was higher than 3 on 9/23/25, 9/24/25, 10/3/25, 10/4/25, 10/18/25, 10/24/25, 10/30/25, 10/31/25, 11/1/25, 11/3/25, 11/7/25, 11/8/25, 11/9/25, 11/14/25, 11/15/25, 12/17/25, 12/26/25, 12/30/25, 1/2/26, and 1/3/26. The DON stated the licensed nurse should follow the physician order and inform the physician of the residents' pain level.Review of the facility's policy, Pain Assessment and Management, dated 10/2022, indicated . 12. The medication regimen is implemented as ordered.

Based on observation and interviews, the facility failed to ensure food served was palatable and attractive for three of fifty-one residents (Resident 2, Resident 17, and Resident 72). The failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition.Findings: During an interview 1/5/26 at 12:30 p.m., with Resident 2, Resident 2 stated food tasted terrible especially chicken. During an interview on 1/5/26 at 3:24 p.m., with Resident 17, Resident 17 stated the food sometimes is good sometimes is not good. As a result of multiple resident complaints about the food, a test tray evaluation was conducted during the lunch service on 1/7/26 at 1:08 p.m. The Registered Dietician (RD) and the Dietary Supervisor (DS) were in attendance when the test tray contents were sampled by two surveyors. One item on the regular test tray was green beans. The DS stated the green beans are a little bit overcooked and need a little bit of salt, the DS further stated they don't have a steamer. The RD tasted the green beans, and she agreed the green beans are overcooked and stated that it will affect the nutritive value of the food if it is overcooked. Review of the facility's policy and procedure titled, Food and Nutrition Services, revised October 2017 indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. the food appears palatable and attractive, and it is served at a sale and appetizing temperature. A review of Resident 72's clinical record indicated he was initially admitted on [DATE]. Further review of the clinical record indicated Resident 72 was on fortified/high protein diet regular texture. During an interview with Resident 72 on 1/7/26 at 12:51 p.m., he complained that the facility's food was terrible. Resident 72 further described the texture of the green beans served at the facility as soaked and slumpy. During an observation and concurrent interview on 1/7/26 at 1:08 p.m., two surveyors, along with the Registered Dietitian (RD) and Dietary Manager (DM), conducted a taste test of the food the facility served the residents for lunch that day. The facility's menu indicated the lunch consisted of greens for regular diet. During the food tasting the RD, and DM stated the green beans were overcooked. The RD also stated that overcooked green beans could affect the nutritive value of the food.

Based on observation, interview, and record review, the facility failed to ensure food items were stored and prepared in accordance with professional standards for food safety when there was unsanitary baking equipment in the kitchen, four base plate, deformed, dented and discolored covers. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the seventy-nine residents who received food from the facility kitchen.Findings: 1.During the initial kitchen tour observation on 1/5/26 at 10:31 a.m., with the Dietary Supervisor (DS) and the Registered Dietitian, observed four baking pans with blackish discolorations and brownish spots in them. The DS stated they use it for baking and she removed the baking pan to wash it. During a follow-up interview on 1/8/26 at 1:31 a.m., with the Dietary Supervisor (DS), the DS stated the four-baking pan will be replaced with new baking pan. 2. During tray line observation on 1/7/26 at 11:50 a.m., Observed four base plate covers were dented, deformed, and discolored, the staff used it to serve food to residents during lunch. During a concurrent observation and interview on 1/8/26 at 10:29 a.m., with the DS and the RD about the dented, deformed, and discolored base plate covers, the DS confirmed the finding, she stated the base plate covers should be remove and replacing it with new one, then they start checking and removing all base plate covers with dented, deformed, and discolored. Review of the facility's policy and procedure titled, Sanitation, revised 11/2023 indicated, .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair.12. Plastic ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment that cannot be repaired is discarded .

Based on observations, interviews, and record reviews, the facility failed to ensure infection control practices were implemented when: 1.Resident 13 were not placed on Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes.) signage posted and there was no available PPE (Personal Protective Equipment, refers to specialized gear like gloves, gowns, masks, and eye protection that creates a barrier to shield healthcare workers from infectious materials, preventing disease transmission to themselves, patients, and others by stopping contact with germs, blood, or body fluids); 2. Facility unit refrigerator had a box of chicken and mashed potatoes for resident and it was not stored in the freezer as per manufacturing label to keep frozen.3. Licensed vocational nurse A (LVN A) did not sanitize his hands after removing gloves;4. Treatment nurse B (TN B) opened the trash bag with his hand during the treatment on Resident 2's pressure ulcers (areas of damaged skin and tissue caused by sustained pressure);5. Certified nursing assistant D (CNA D) placed Resident 19's soiled linen on top of the trash can and against the wall;6. Resident 46's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask and tubing were not store in the bag ; and7. The filter of Resident 47's oxygen concentrator was dusty. These failures had the potential to cause foodborne illnesses to residents, spread infections to residents, staff, and visitors.Findings: 1.During a review of Resident 13's clinical record, it indicated Resident 13 was admitted to the facility with diagnosis including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications. During a review of Resident 13's physician order indicated an order, dated 12/30/25 Stage II pressure injury (a shallow open sore involving partial-thickness skin loss, appearing as a pink or red wound bed (dermis exposed) or a serum-filled blister, indicating damage to the epidermis and upper dermis but not deeper tissues like fat or bone.) to right heel: clean with NS (normal saline) pat dry, apply Santyl (a prescription topical ointment that enzymatically removes dead (necrotic) tissue from wounds, like ulcers and severe burns, to promote healing and new skin growth without harming healthy tissue, working by breaking down collagen in the dead tissue) and Gentamicin (used to treat serious bacterial infections in many different parts of the body) and cover with foam dressing. During an observation on 1/6/2026 at 12:22 p.m., outside Resident 13's entrance door there was no blue sticker next to Resident 13's name, indicated Resident 13 was not place on EBP. During an interview and record review on 1/08/2026 at 1:59p.m., with the infection control preventionist (IP), the IP reviewed Resident 13's clinical records and confirmed Resident 13 has stage II pressure injury to right heel, the IP stated Resident 13 was not on EBP, the IP further stated resident with stage II pressure injury they should have EBP and she missed this one. During a review of the facility's policy and procedures titled, Enhanced Barrier Precautions, revised 6/2024, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.5.EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.6.EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 2. During a concurrent observation and interview in resident's refrigerator unit at station AA on 1/8/26 at 1:03 p.m., with the Infection Control Preventionist (IP), found inside the refrigerator a box of chicken & mashed potatoes, dated 5/25/24 with name of Resident 8, on the manufacturing box indicated Perishable. Keep Frozen. [NAME] Thoroughly. The IP stated it should be stored in the freezer. During a follow-up interview on 1/9/26 at 10:13 a.m., with the IP about Resident 8's box of chicken and mashed potatoes stored in the refrigerator, the IP stated she asked the staffs, and they don't know since when it was stored in the fridge, The IP further stated it should be stored in the freezer and it was thrown away. During an interview on 1/9/26 at 1:37 p.m., with the Dietary Supervisor (DS), the DS reviewed state phone's photo of Resident 8's box of chicken and mashed potatoes, the DS stated the 5/25/24 is the date of received and should be in the freezer, if in the fridge it should have thawing date. During a review of facility's policy and procedure titled Food Receiving and Storage, revised 11/2022, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices.Refrigerated/Frozen Storage1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) .8. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. 3. During a medication pass observation on 1/5/26, at 11:58 a.m., after administering 12 units of insulin aspart (used to control blood sugar) to Resident 30, LVN A removed his gloves then charting on the computer on his medication cart without sanitizing his hands. During a concurrent interview with LVN A, he stated he should sanitize his hands after removing his gloves. Review of the facility's policy, Handwashing/Hand Hygiene, dated 10/2023, indicated . 1. Hand hygiene is indicated: . g. Immediately after glove removal. 4. During treatment observation on Resident 2's left ischium (sit bone in the lower part of the hip) and right hip pressure ulcers on 1/8/26, at 10:03 a.m., after removing the old dressings and gauze from Resident 2's wounds, TN B washed his hands and put on gloves. TN B cleansed Resident 2's wounds, opened the trash bag with his hand to throw the soiled gauze in there, patted dry the wounds, opened the trash bag with his hand to throw the soiled gauze in there, then continued to apply Dakin (used to clean infected topical wounds) moistened gauze into the wound bed and apply dry gauze. During an interview with TN B on 1/8/25, at 10:35 a.m., TN B confirmed that his hands were contaminated during the treatment on Resident 2's wounds because he had to open the trash bag with his hand every time, he threw soiled material in there. Review of the facility's policy, Handwashing/Hand Hygiene, dated 10/2023, indicated . 1. Hand hygiene is indicated: . c. After contact with blood, body fluids, or contaminated surfaces. 5. During an observation and interview with CNA D in Resident 19's room on 1/5/26, at 10:51 a.m., soiled linen was placed on top of the trash can and lying against the wall. CNA D stated she prepared Resident 19 for shower, and the soiled linen should not be placed on top of the trash can and lying against the wall. CNA stated the soiled linen should be put in the soiled linen bin. During an interview with the infection preventionist (IP) on 1/8/26, at 2:08 p.m., she stated the soiled linen should not be placed on top of the trash can and lying against the wall. The soiled linen should be put in the soiled linen bin. Review of the facility's policy, Laundry and Bedding, Soiled, dated 9/2022, indicated . a. Contaminated laundry is bagged or contained at the point of collection. 6. Review of Resident 46's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 46's physician order, dated 1/2/26, indicated she had an order for ipratropium-albuterol (used to open up the airways) 0.5-2.5 milligrams (mg, a metric unit of mass)/3 milliliters (ml, a metric unit of volume) inhale via nebulizer every 6 hours as needed for shortness of breath. During an observation and interview with LVN A on 1/5/26, at 11:30 a.m., Resident 46's nebulizer mask was in drawer of the cabinet next to her bed and the nebulizer tubing was hanging down in front of the cabinet. LVN A stated that the nebulizer mask and tubing should be stored in the bag. During an interview with the IP on 1/8/26, at 2:10 p.m., she stated that the nebulizer mask and tubing should be stored in the bag. 7. Review of Resident 47's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 47's physician order, dated 10/15/24, indicated he had an order for oxygen 2 liters (L, a metric unit of volume) per minute as needed for oxygen saturation (blood oxygen level) less than 92%. During an observation and interview with LVN A on 1/5/26, at 11:19 a.m., the filter of Resident 47's oxygen concentrator was dusty. LVN A stated the filter of the oxygen concentrator should have been cleaned every week. During an interview with the IP on 1/8/26, at 2:12 p.m., she stated the filter of the oxygen concentrator should be kept clean and cleansed every week.

Based on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 61) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). This failure had the potential for inaccurate care and services provided to residents with mental disorder, intellectual disability, or related conditions. Findings:Review of Resident 61's clinical indicated he was admitted to the facility with diagnoses including paranoid schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Review of Resident 61's preadmission PASRR Level 1 screening, dated 11/26/25, it was indicated Resident 61 had a positive Level I screening which indicated he should have a Level II Mental Health Evaluation. Review of Resident 61's letter from the California Department of Health Care Services (DHCS) with a subject, Notice of Attempted Evaluation, dated 11/29/25, indicated a Level II evaluation was not completed. It indicated a Level II evaluation was not scheduled for the following reason: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. During an interview on 1/09/2026 at 11:13 a.m., with the Administrator-in-Training (AIT), the AIT stated Resident 61 PASSR Level II evaluation was not completed, the AIT further stated the facility should have follow up with PASSR. Review of the facility's policy, PASSR, revised 1/2024 indicated, The facility must not admit, on or after January I, 1989, any new residents with a mental disorder as defined, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission. PASRR requires that 1)all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability .

Based on observation. interview, and record review, the facility failed to develop and implement comprehensive care plan for one of 28 sampled residents (Resident 35) when Resident 35's care plan did not reflect his noncompliance behavior to safety and well-being. This failure had the potential to compromise the facility's ability to implement interventions.Findings: During a concurrent observation and interview with the IP on 1/6/26 at 12:47 a.m., in resident's room, the IP confirmed the extension cord, phone charger, bags, clothes, papers, power wheelchair battery charger, and plastic bags were placed under Resident 35's bed. The IP described Resident 35's had behavior for noncompliant. The IP further stated that noncompliant behavior should have been documented and care planned. During a concurrent interview and record review with the DON on 1/7/26 at 11:18 a.m., the DON explained that Resident 35 preferred to put everything on his bed and described Resident 35 as noncompliant to potential accident hazard. The DON confirmed that there was no care plan in place addressing Resident 35's noncompliant behavior to removal of potential accident hazard of power strip, excess electrical cords, and power wheelchair battery charger in resident 35's bed. A review of Resident 35's clinical record, indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of four limbs), C1-C4 incomplete; chronic pain syndrome; major depressive disorder (mental disorder), recurrent, unspecified; other abnormalities of gait and mobility; personal history of other mental and behavioral disorders; obesity, unspecified; acquired absence of left leg above knee . The record also indicated Resident 35 had a BIMS (Brief Interview for Mental Status) score of 15, dated 10/8/25 (a score of 15 indicates the resident's cognition is intact). A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2023, the P&P indicated, 7. The comprehensive, person-centered care plan: (b.1.) describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided for the above, but not provided due to the resident exercising his or her rights, (e) reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to provide services that meet professional standards for two of 18 sampled residents (2 and 26) when:1. Zinc Oxide cream (used to treat and prevent diaper rash) was left on top of Resident 26's bedside drawers; and 2. Treatment nurse B (TN B) used Dermal Wound Cleanser (a liquid used to gently clean and helps remove dirt and debris from chronic and acute wounds) to cleanse Resident 2's wounds instead of normal saline (NS, a mixture of water and salt with a salt concentration of 0.9%) as ordered by the physician. These failures had the potential to negatively affect the wound healing, and the residents might access the medication.Findings:1. During an observation and interview with licensed vocational nurse A (LVN A) on 1/5/26, at 11:10 a.m., a medicine cup with white substance inside was on top of Resident 26's bedside drawers. LVN A stated it was the cup of zinc oxide cream for Resident 26's treatment, and it should not be left with the resident.Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. 2. Review of Resident 2's admission Record indicated she was admitted to the facility on [DATE] with pressure ulcer (areas of damaged skin and tissue caused by sustained pressure) of right hip and left buttock diagnoses.Review of Resident 2's physician orders, dated 12/16/25 and 12/24/25, indicated she had orders for the licensed nurse to cleanse her right hip and left ischium (lower-rear portion of the hip bone) pressure ulcers with NS, pat dry, apply Dakin (a strong topical antiseptic solution) moistened gauze into wound bed, apply dry gauze, cover with border foam dressing two times a day and as needed.During a treatment observation with TN B on 1/8/26, at 10:03 a.m., TN B cleansed Resident 2's right hip and left ischium pressure ulcers with dermal wound cleanser not NS.During an interview with TN B on 1/8/26, at 10:35 a.m., he reviewed Resident 2's physician orders and confirmed that the physician ordered to cleanse Resident 2's right hip and left ischium pressure ulcers with NS, but he cleansed them with dermal wound cleanser. TN B stated he should use NS to cleanse Resident 2's wounds as ordered by the physician.Review or the facility' policy, Wound Care, dated 2/2024, indicated . 9. Apply treatment as indicated.

Based on interview and record review, the facility failed to ensure one of two residents (19) receive care and services for the provision of dialysis (procedure to remove waste or toxins from the blood and adjust fluid and electrolyte imbalances) consistent with professional standards of quality when licensed vocational nurse C (LVN C) did not know how to check Resident 19's bruit (an audible vascular sound associated with turbulent blood flow usually heard with the stethoscope). This failure had the potential for delayed detection, reporting, and management of complications from the dialysis shunt for the residents. Findings:Review of Resident 19's admission Record indicated she was admitted to the facility on [DATE] with dependence on renal dialysis diagnosis. Review of Resident 19's physician order, dated 12/21/25, indicated she had an order for the licensed nurse to monitor bruit and thrill (the normal, buzzing vibration felt over a dialysis shunt) of dialysis shunt every shift. During an interview with LVN C on 1/8/26, at 4:08 p.m., she stated she checked Resident 19's both bruit and thrill by feeling the dialysis shunt with her fingers. Review of the facility's policy, End-Stage Renal Disease, Care of a Resident with, dated 9/2010, indicated . 2. Education and training of staff includes, specifically: . g. The care of grafts and fistulas .

Based on interview and record review, the facility failed to ensure two of 28 sampled residents (Resident 1 and Resident 35) were free from unnecessary medications when: 1. Resident 1 received Nuedexta (used to treat pseudobulbar affect [PBA, a medical condition that causes involuntary, sudden, and frequent episodes of crying]) and was not monitored for episodes of crying. This failure resulted in the effectiveness of Nuedexta being undetermined, and Resident 1 might have unnecessary adverse effects. 2. Resident 35 did not have adequate monitoring for the side effect and adverse reaction of the antibiotic medication therapy. This failure had the potential for side effects and adverse reaction of the antibiotic to go undetected or recognized for timely interventions.Findings: 1. Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with PBA diagnosis. Review of Resident 1's physician order, dated 7/29/24, indicated she had an order for Nuedexta 20 to 10 milligrams (mg, a metric unit of mass) two times a day for episodes of uncontrolled crying. However, there was no indication that Resident 1's episodes of uncontrolled crying were monitored. During an interview with the director of nursing (DON) on 1/9/26, at 1:02 p.m., he reviewed Resident 1's clinical record and confirmed that Resident 1's episodes of uncontrolled crying were not monitored. The DON stated Resident 1's episodes of uncontrolled crying should be monitored. Review of the facility's policy, Medication Therapy, dated 4/2007, indicated 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. A review of Resident 35's clinical record indicated he was admitted at the facility on 5/26/20 with diagnosis including carrier or suspected carrier of methicillin resident staphylococcus aureus. Further review of Resident 35's clinical record, he had physician order dated 1/4/25, indicated Piperacillin Sod-Tazobactam Solution Reconstituted 3-0.375 gram intravenously (IV) every 6 hours for Carbapenem Resistant Pseudomonas Aeruginosa (CRPA) for 7 Days. During a concurrent interview and record review with the IP on 1/8/26 at 1:41 p.m., the IP stated that Resident 35 started the IV Piperacillin Sodium Tazobactam on 1/5/26. The IP confirmed that there were no monitoring in place for the side effect and adverse reaction of the antibiotic in Resident 35's medical record. A review of the facility's policies and procedures titled, Administering Medications, revised April 2023, and Medication Therapy, revised April 2007, the P&P indicated, As required or indicated for a medication, the individual administering the medication records in the resident's medical record: any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed .; Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether potential or suspected side effects are present.the staff and practitioner will review the medication regimen for continued indications, proper dosage, and duration, and possible adverse consequences.

Based on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident.Findings:room [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 3 beds, 77.7 square feet per residentroom [ROOM NUMBER], 2 beds, 74 square feet per residentroom [ROOM NUMBER], 3 beds, 77.7 square feet per residentroom [ROOM NUMBER], 2 beds, 76 square feet per residentroom [ROOM NUMBER], 2 beds, 77 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 3 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 70 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 71 square feet per residentroom [ROOM NUMBER], 3 beds, 74 square feet per residentroom [ROOM NUMBER], 3 beds, 74 square feet per residentroom [ROOM NUMBER], 3 beds, 74 square feet per residentroom [ROOM NUMBER], 2 beds, 76 square feet per residentroom [ROOM NUMBER], 3 beds, 78.5 square feet per residentroom [ROOM NUMBER], 2 beds, 71 square feet per residentroom [ROOM NUMBER], 3 beds, 72 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 3 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 3 beds, 72 square feet per residentroom [ROOM NUMBER], 2 beds, 73 square feet per residentroom [ROOM NUMBER], 3 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 70.8 square feet per residentroom [ROOM NUMBER], 3 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 70.8 square feet per residentroom [ROOM NUMBER], 3 beds, 73 square feet per residentroom [ROOM NUMBER], 2 beds, 70.8 square feet per residentroom [ROOM NUMBER], 3 beds, 70.5 square feet per residentroom [ROOM NUMBER], 3 beds, 72.3 square feet per resident During multiple observations on 1/5/2026 through 1/9/2026, none of the rooms were observed to inhibit the staff providing care. The staff and the residents moved freely in the rooms. The residents and the staff stated the square footage of the rooms was not a concern.Continuance of the room waiver is recommended.

Based on observation, interview and record review, the facility failed to store and prepare food under sanitary conditions in accordance with professional standards when: 1. Steel trays with black stains were found inside the kitchen freezer; 2. The ice machine had black substance build up found inside and yellow stain on the baffle; 3. Dietary staffs did not wear hairnet/beard restraints while inside the facility kitchen and; 4. Facility did not follow their policy and procedure regarding labeling of foods brought in by family or visitors for one out of two sampled residents (Resident 237). These failures had the potential to expose residents to contaminants that could cause foodborne illness. Findings: 1. During the initial kitchen tour on 8/12/24 at 9:44 a.m. with Dietary Supervisor (DS), two steel trays with visible black stains on the edges were found inside the facility freezer. DS took out the trays from the freezer. A review of facility's policy and procedure titled Sanitization revised October 2008, the P& P indicated, 2. All utensils, counters, shelves and equipment shall be kept clean and maintained in good repair 2. During a concurrent observation and interview on 8/12/24 at 2:15 p.m. with Registered Dietician (RD), the facility ice machine had black substance build up inside. RD stated that housekeeping department cleans the ice machine once every month and a contracted company comes every six months to check and clean the ice machine as per manufacturer guidelines. During a concurrent observation and interview on 8/12/24 at 2:41 p.m. with Housekeeping Manager (HKM) and Maintenance Supervisor (MS), HKM opened the top part of the ice machine and took out the baffle. HKM and MS confirmed yellow stain and black substance build up were observed along the edges of the baffle. HKM stated that housekeeping department cleans the ice machine once a month. A review of facility's policy and procedure (P&P) titled Sanitization revised October 2008, P&P indicated, Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy 3. During an observation on 8/12/24 at 2:03 p.m. with DS in the facility kitchen, DS confirmed Dietary [NAME] (DC) E, had a head cap on and hair was not fully covered, Dietary Aide (DA) J wore a head cap, long hair in loose braid without hairnet and Dietary Aide (DA) F had facial beard exposed without covering. DS stated they should have worn a hairnet and beard must be covered. During an interview on 8/12/24 at 2:22 p.m. with DA F, DA F stated Sometimes, I forget to cover my beard. A review of facility document titled In-Service Meeting Minutes dated 4/12/24, indicated, RD was the lecturer of the in-service with the topic Hair Restraint and Fingernail/Hand Hygiene. Summary of lecture indicated,Proper use of hairnets, caps, and beardguards during food prep, service and all duties within the kitchen. Appropriate fingernail length and coatings. The document also indicated, .Hairnets or other hair restraints need to cover all hair to prevent it falling into food and other contact surfaces. Hat comes off hairnet goes on!!! .Staff who have facial hair need to wear a beard restraint. DC E, DA J and DA F were listed as attendees of the in-service. A review of facility's policy and procedure (P&P) titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices revised October 2017, the P&P indicated, 12. Hair nets, caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. 4. During a concurrent observation and interview on 8/19/24 at 10:39 a.m. with Licensed Vocational Nurse (LVN) K of a facility refrigerator which stored foods brought-in by resident's relatives, LVN K confirmed a re-sealable bag of cooked French fries had a written date of 8/17/24 and Resident 237's name. LVN K also confirmed another re-sealable bag of cooked chicken strips with written date of 8/17/24 had Resident 237's name. LVN K stated the written date on both bags was the date on when it was received. LVN K stated they usually keep brought- in foods for three days. During a concurrent interview and record review on 8/19/24 at 2:37 p.m. with Director of Nursing (DON), DON confirmed that according to facility's policy and procedure regarding brought-in foods, brought-in foods should be labeled with the date on when it should be discarded. DON agreed they should follow the facility policy and procedure. A review of facility's policy and procedure (P&P) title Foods Brought by Family/Visitors revised December 2021, the P&P indicated, Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the 'use by' date (maximum of 72 hours).

Based on observation, interview, and record review, the facility failed to develop and implement care plans for five of five residents (Residents 19, 66, 78, 238, and 59): 1. For Resident 19, the facility did not develop care plan for activities of daily living (ADLs, a term used to describe the basic skills needed to independently care for oneself) to address hygiene and did not implement the anticoagulant therapy (sometimes called blood thinning medicines that reduces blood clots and can cause bleeding) care plan; 2. For Resident 66, the facility did not develop care plan for Urinary Tract Infection (UTI- an illness that often start when bacteria get into the tube through which urine leaves), and the physician order of Ciprofloxacin Hydrochloride (medication for bacterial infections). 3. For Resident 78, the facility did not develop care plan for UTI and the physician order of Cephalexin Oral Capsule (medication for bacterial infections). 4. For Resident 238, the facility did not develop care plan for the use of two medication Zoloft (medication for depression) and Aripiprazole (an antipsychotic medication). 5. For Resident 59, the facility did not develop care plan for alendronate sodium (a medication to prevent bone breakdown and increase bone thickness) and for concave mattress (also called a scoop mattress, designed with raised edges, or contoured sides that 'scoop' upward, creating a barrier to help prevent users from rolling off the bed) used. These failures had the potential to result in not having the specific care and services necessary to meet Residents 19, 66, 78, 238, and 59's needs. Findings: 1a. Review of Resident 19's Admission Record, indicated Resident 19 was admitted to the facility with diagnoses including nondisplaced (still broken bones, but the pieces weren't moved far enough during the break to be out of alignment) intertrochanteric fracture of left femur (broken thigh bone), colles fracture of left radius (break in forearm bone, near the wrist), type 2 diabetes mellitus (DM, occurs when the body is unable to regulate glucose [sugar] in the blood), unspecified atrial flutter (a type of heart rhythm disorder in which the heart's upper chambers beat too quickly), and sheltered homelessness (people spend the night in emergency shelters or in transitional, or temporary housing). Further review indicated Resident 19 was a female. Review of Resident 19's admission minimum data set (MDS, an assessment tool) assessment dated [DATE], indicated, Resident 19's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]); [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] score was 15. Further review indicated, Resident 19 required partial/moderate physical assist (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with personal hygiene and upper body dressing. During an observation on 8/12/2024 at 10:47 a.m., at the hallway near Resident 19's room, Resident 19 was seated on a wheelchair and was able to propel self along the hallway with the used of her legs. Resident 19 was observed to have noticeable black and gray mustache and beard. During a concurrent observation and interview with Resident 19 on 8/13/2024 at 4:30 p.m., inside Resident 19's room, she was in bed, her shirt had some food dripping stains, still with facial hair and fingernails were about half inch long with brownish substance build up underneath. Resident 19 confirmed she did not want to be shaved. Resident 19 stated, if only she had the cream to apply to her mustache and beard, it would easily fall off. Resident 19 also declined to trim her fingernails. During an interview with licensed vocational nurse H (LVN H) on 8/16/2024 at 9:54 a.m., LVN H stated Resident 19 refused to be shaved when they attempted. LVN H confirmed Resident 19 was admitted with facial hair and it should have been care planned for staff to know how to care for Resident 19. During an interview with director of nursing (DON) on 8/19/2024 at 2:16 p.m., DON stated Resident 19 should have a care plan for staff to know how to manage her hygiene. During a review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, date revised March 2023, indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .5. Interventions to improve or maintain a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, date revised March 2023, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from analysis of the information gathered as part of the comprehensive assessment .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 1b. Review of Resident 19's physician's order, dated 6/18/2024, indicated, Apixaban [Brand name: Eliquis, an anticoagulant medication] Oral Tablet 2.5 MG [milligram, unit of measurement] (Apixaban) Give 1 tablet by mouth two times a day for dvt [deep vein thrombosis, occurs when a blood clot forms in one of more of the deep vein in the body, usually in the legs] prophylaxis [the prevention of disease or the control of its spread]. Review of Resident 19's care plan titled, Anticoagulant therapy, dated 6/19/2024, interventions indicated, Daily skin inspection. Report abnormalities to the nurse. Monitor/document/report to MD [medical doctor] PRN [pro re nata, which means as needed] s/sx [signs and symptoms] of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB [shortness of breath], Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs: blood pressure, respiration rate, temperature, heart rate]. During a concurrent interview with LVN H and record review on 8/16/2024 at 9:44 a.m., LVN H reviewed Resident 19's medication administration record (MAR). LVN H confirmed Resident 19 was taking an anticoagulant. LVN H stated, nurses should have monitored Resident 19 for any s/sx of bleeding. LVN H further stated, they usually document the monitoring of s/sx of bleeding in the MAR but LVN H confirmed it was not documented. During an interview with interim director of nursing (IDON) on 8/16/2024 at 1:11 p.m., IDON stated, nurses should have monitored Resident 19 for s/sx of bleeding for anticoagulant use. During an interview with DON on 8/19/2024 at 2:36 p.m., DON stated, there should be monitoring of s/sx of bleeding for Resident 19 as care planned. DON further stated, the monitoring should be documented in Resident 19's MAR. During a review of the facility's policy and procedure titled, Anticoagulation - Clinical Protocol, date revised November 2023, indicated, The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. A. If an individual on anticoagulation therapy show signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. 46553 2. Review of Resident 66's Admission Record, indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including Encounter for Palliative Care(specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), Obstructive and reflux uropathy (a condition in which the flow of urine is blocked), personal history of malignant neoplasm (refer to an abnormal growth of tissue). Reviewed of Resident 66's admission MDS assessment dated [DATE] indicated, Resident 66's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]); [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] score was 13. Review of Resident 66's physician's order, dated 5/9/2024, indicated, Ciprofloxacin Hydrochloride Oral Tablet 500 MG [milligram, unit of measurement] Give 1 tablet by mouth at bedtime for status post nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) placement for 2 days. During a review of Resident 66's Antibiotic Time Out Record, indicated with presenting clinical symptoms of UTI, positive Morganella Morganii (a gram -negative considered as an unusual opportunistic pathogen [organism or agent that can produce disease] that mainly causes post-operative wound and urinary tract infections. During a record review of Resident 66's clinical records, no care plan was developed for UTI and for the medication Ciprofloxacin Hydrochloride Oral Tablet 500 MG. During a concurrent interview and record review on 8/15/24 at 10:30 a.m., with Minimum Data Set Nurse (MDSN), she confirmed no care plan was develop for Urinary Tract Infection (UTI an illness that often start when bacteria get into the tube through which urine leaves) and the medication Ciprofloxacin Hydrochloride. MDSN stated I don't see a care plan for the UTI. There should be a care plan for UTI and the use of Ciprofloxacin HCL. 3. Review of Resident 78's Admission Record, indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including Fractured of Shaft (a long slender cylindrical [ a tubular form] body or part) of Right Femur, Asthma (a condition in which a person's airway become inflamed, narrow, and swell, and produce extra mucus, which makes it harder to breath. Hypertension (a condition in which the force of the blood against the artery walls is too high. Bilateral primary osteoarthritis of hips (the cartilage in the hip joint gradually wears away over time), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region. Reviewed of Resident 78's quarterly MDS assessment dated [DATE] indicated, Resident 78's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]); [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] score was 8. Review of Resident 78's physician's order, dated 5/30/2024, indicated, Cephalexin Oral Tablet 250 mg Give 2 capsule by mouth every 8 hours for UTI for 5 days. During a record reviewed of Resident 78's electronic Medication Administration Record (eMAR) for the month of May 2024. Resident 78 received the medication from 5/30/24, 5/31/24, 6/1/24, 6/2/24, 6/3/24, 6/4/24 Time 06:00, 14:00, 22:00. During a record reviewed of Resident 78's clinical records, no care plan was developed for UTI and for the medication order of Cephalexin Oral Capsule. During a concurrent interview and record review on 8/15/24 at 10:37 a.m., with MDSN, she confirmed no care plan was developed for UTI and the medication Cephalexin. MDSN stated Care plan are initiated upon admission, then we update the care plan. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person Centered, dated revised March 2023, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical psychosocial and functional needs is develop and implemented for each resident.11. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 4. Review of Resident 238's Admission Record, indicated Resident 238 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder (characterized by feelings of worry, or fear that interfere with one's daily activities), Dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and Depression (condition of mental and behavioral disorder that causes intense shifts in mood, energy levels, thinking patterns and behavior). During record review of Resident 238's Order Summary Report for the month of August 2024, Resident 238 has physician order for Aripiprazole Oral Tablet 20 mg (Aripiprazole) Give 1 tablet by mouth one time a day manifested by (m/b) verbalization of sadness verified informed consent signed by MD (Medical Doctor) and Zoloft Oral Tablet 50 mg ( Sertraline HCL ) Give 1 tablet by mouth one time a day for Depression and Anxiety m/b verbalization of sadness; Informed consent obtained and signed by MD with order date of 7/26/24. During a record review of Resident 238's clinical records, no care plan was developed for the medication order of Zoloft and Aripiprazole. During a concurrent interview and record review on 8/15/24 at 3:15 p.m., with MDSN, she confirmed no care plan was develop for the used of the medication Zoloft and Aripiprazole. MDSN stated any order should be care plan for both medication Zoloft and Aripiprazole (Abilify). During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person Centered, dated revised March 2023, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. 10. When possible, interventions addresses the underlying source(s) of the problem area(s), not just symptoms or trigger. 11. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 50855 5a. During a review of Resident 59's Admission Record on 08/16/24 at 09:03 a.m., Indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses includes Contracture(a condition of shortening and hardening of muscles, tendons, or other tissue) of left knee, Hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), asthma (A condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). Uncomplicated, Vitamin D deficiency (don't have enough vitamin D in your body) During a review of Resident 59's clinical record indicated, he has a physician order dated, 02/09/2024 Alendronate sodium oral tablet 70 milligram (mg) give one tablet by mouth one time a day every thu (Thursday) for osteoporosis (A condition in which bones become weak and brittle). There was no care plan developed for Osteoporosis and alendronate. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 08/16/24 at 01:34 p.m., IDON stated, Resident 59 has no care plan developed for Osteoporosis, it should have a care plan in place for osteoporosis. 5b. During an observation on 08/12/24 at10:47 a.m., Resident 59 was lying on bed, using concave mattress with 1/4 bilateral (Both Side) rails up, Watching TV. During a concurrent observation and interview with Interim Director of Nursing (IDON) on 08/14/24 at 10:57 a.m., IDON stated, Resident 59 use the concave mattress, there should be a physician order and it should be care planned. During a concurrent interview and record review with Interim Director of Nursing (IDON)on 08/14/24 at 11:00a.m., IDON stated, Resident 59 has no concave mattress care plan. IDON stated, not sure why resident 59 is using a concave mattress with bed rails, will find out and comeback to you. During a concurrent interview and record review with Infection Prevention (IP) and Interim Director of Nursing (IDON) on 08/14/24 at 01:28 p.m., IP stated, it's a reminder for Resident 59 not to fall out of bed, it is a fall intervention, and it should be care planned. IP confirmed Resident 59 has no care plan related to the use of concave mattress. Review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person Centered, dated revised March 2023, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. 10. When possible, interventions addresses the underlying source(s) of the problem area(s), not just symptoms or trigger. 11. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions for two out of three medication rooms and two out of three medication carts when: 1. There was an outdated vial (cylindrical container) of tuberculin (liquid used to test for tuberculosis) in the medication refrigerator in med storage CC; 2. There was an open, unlabeled Ozempic (medication used to lower blood sugar) injection pen in the medication refrigerator in med storage CC; 3. There were three medications in med cart BB that were not refrigerated as ordered; 4. There were two outdated antiperspirants and one outdated biohazard spill kit (a collection of materials used to clean up blood, vomit, mucus, saliva, and other bodily fluids) in med storage CC; 5 Two over the counter (OTC) eye medication bottles, for two residents were identified in the medication cart; and 6. A medication Eplerenone 25 mg tablet on the blister pack label was not the same order as the physician order. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors. Findings: 1. During an observation of med storage CC and concurrent interview with Licensed Vocational Nurse K (LVN K) on 8/12/24, at 2:00 p.m., there was a vial of Tuberculin in the medication refrigerator. The container for the Tuberculin vial had an open date of 7/3/24. The instructions printed on the container indicated to discard 30 days after opening. LVN K confirmed this observation and acknowledged the vial of Tuberculin was outdated. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P& P indicated, 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specified a shorter or longer date for the open vial. 2. During an observation of med storage CC and concurrent interview with LVN K on 8/12/24, at 1:56 p.m., there was one open Ozempic injection pen in the medication refrigerator. The box was labeled with the resident's name, but the Ozempic injection pen itself was unlabeled. LVN K verified this observation and acknowledged that if the box were lost or destroyed, the unlabeled Ozempic injection pen had the potential to result in a medication error. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage dated 2/2023, the P& P indicated, 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 3a. During an observation and concurrent interview with LVN A on 8/14/24, at 3:30 p.m., there were two unopened bottles of latanoprost ophthalmic solution 0.005% eye drops (medication used to treat glaucoma) in med cart BB. The instructions printed on the medication packaging indicated, REFRIGERATE. LVN A confirmed this observation and acknowledged the medication was not refrigerated. 3b. During an observation and concurrent interview with LVN A on 8/14/24, at 3:45 p.m., there was an unopened Insulin Glargine U 100 pen (medication used to lower blood sugar) in med cart BB. The instructions printed on the medication packaging indicated, REFRIGERATE. LVN A confirmed this observation and acknowledged the medication was not refrigerated. 3c. During a concurrent medication cart inspection and interview on 8/14/24 at 3:45 p.m., with LVN Q, an unopened Insulin Humalog 100-unit pen was on the med cart EE drawer not stored in the refrigerator. On the medication packaging indicated REFRIGERATE, LVN Q verified the medication was not opened and not stored in refrigerator. LVN Q stated it should be refrigerated if not yet in use. During an interview with the Interim Director of Nursing (IDON) on 8/16/24, at 1:55 p.m., the IDON stated if the facility receives new medications from the pharmacy, the medications should be refrigerated and not removed until used. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage dated 2/2023, the P&P indicated, 6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location. Medications are stored separately 4. An inspection of the medication storage CC, was conducted with LVN L on 8/12/24, at 2:06 p.m., as follows: a. An unopened plastic of Biohazard (a biological substance that poses a threat to the health of living organism, primarily that of human) Spill Kit (used to handle liquid biohazards like blood) with expiration date of 03/13/21. LVN L confirmed that was expired and not being used. b. Two bottles of anti -perspirant deodorant spray with expiration of 06/24. LVN L confirmed that was expired and stated those are part of house supply. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, Medication Ordering and Receiving from Pharmacy, dated April 2024, the P&P indicated, Medication are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy can modify or change prescription labels. 5. During a concurrent medication cart BB inspection and interview with LVN A on 8/14/24 at 3:38 p.m., two over the counter (OTC) eye medication bottles, for two residents were identified in the medication cart: 2 bottles of Artificial Tears (for eye lubrication). The eye drops were labeled (handwritten) with only residents' room number and date open on the carton. They had no residents' names on the eye drop. LVN A verified the findings and acknowledge patients have room change from time to time, and the labeling had the potential for the resident to receive this medication in error. She further stated the medication should have a name on the bottles. During an interview on 8/16/24 at 2:00 p.m., with Interim Director of Nursing (IDON), stated room number is not acceptable, because there are times room changes. The name of resident and date open should be in the bottle itself. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated April 2024, the P&P indicated, Medication are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy can modify or change prescription labels. A. Labels are permanently affixed to the outside of the prescription container. No medication is accepted with the label inserted into a vial. If a label does not fit directly on the product, e.g., eye drops, the label may be affixed to an outside container or carton, but the resident 's name, at least, must be maintained directly on the actual product. 6. During a concurrent medication cart AA inspection and interview with LVN K on 8/14/24 at 11:17 a.m., a medication Eplerenone 25 mg tablet on the blister pack label Take 1 tablet (25 mg total) by mouth daily with medication order of Eplerenone Oral Tablet 50 MG (Eplerenone) Give 1 tablet by mouth one time a day for Hypertension (HTN) HOLD for SBP under 110. LVN K verified the medication order was Eplerenone 50 mgs. LVN K acknowledge it can cause medication error. During an interview on 8/16/24 at 1:52 p.m., with IDON, she stated nurses giving medication pass should follow the 5 Rights, making sure the bubble pack is right and compared with the physician order. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, 7. If medication container has missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instruction

Based on observations, interviews, and record reviews, the facility failed to ensure the food was prepared by methods that conserved nutritive value and appearance when eight out of 18 resident sample (Residents 51, 6, 26, 20, 17, 192, 59, and 41) stated facility food was served cold without flavor and not at the appropriate texture. These deficient practices had the potential to decrease the food intake of residents and negatively impact their nutritional status. Cross Reference F803 Findings: During an interview on 8/12/24 at 10:12 a.m. with Resident 51, Resident 51 stated food is not very good and had no taste. During an interview on 8/12/24 at 10:15 a.m., with Resident 6, Resident 6 stated that food was absolutely horrible. During an interview on 8/12/24 at 10:23 a.m. with Resident 26, Resident 26 stated food was inedible, and meat was tough. During an interview on 8/12/24 at 10:34 a.m., with Resident 20 and Resident 17, Resident 20 stated that meatloaf was bland and had no seasoning. Resident 17 stated she was served fried egg that was hard to cut with a knife. Resident 17 also stated that on weekends, foods served were not to Resident 17's liking. During an interview on 8/12/24 at 10:46 a.m., with Resident 192, Resident 192 stated food was horrible and was hard to chew. During an interview on 8/12/24 at 10:47 a.m., with Resident 59, Resident 59 stated that chicken was too dry. During an interview on 08/13/24 at 11:33 a.m. with Resident 41, Resident 41 stated, Food is bad and sometimes cold. A test tray evaluation was conducted due to resident complaints on 8/13/24 at 1:39 p.m. with Registered Dietician (RD) and Dietary Supervisor (DS) for the regular and puree meals. The meal was tested for taste, temperature, and palatability. The chicken and vegetables for both textures tasted bland. The pureed chicken was dry. The pureed bread was bland. The food temperatures were: pureed vegetables, 114.1 Fahrenheit (F, unit of temperature measurement), pureed bread, 118 F, pureed chicken 113.9 F, pureed rice, 117.4 F, regular chicken 112.9 F, regular rice, 116.5 F, and cold milk, 50.8 F. A review of facility document titled In-Service Meeting Minutes dated 4/12/24, indicated, RD was the lecturer of the in-service with the topic Food Temperature/Danger Zone. Summary of lecture indicated, Discussed temperature danger zone, hot and cold temps for food safety. Food temps prior to food service and proper reheating techniques. The document indicated, Cold food items need to be at 41 or below. Hot food items need to be at 135 or above. According to the New Dining Practice Standards dated in 2011 by the [NAME] Regulatory Task Force, food and dining requirements are core components of quality of life and quality of care in nursing homes . 50855

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant N (CNA N) and certified nursing assistant O (CNA O) did not perform hand hygiene when serving lunch trays; 2. Resident 187's nebulizer mask (a device used to convert a drug from liquid form into a mist, inhaled through the mask) was not properly stored when not in used and undated; 3. Licensed Vocational Nurse C (LVN C) did not disinfect the blood pressure (BP) apparatus (BP apparatus, a cuff that is wrapped around the arm to measure BP) in between residents; 4. Resident 238's nebulizer tubing was outdated and left on top of the resident's bedside table; 5. Resident 50's humidifier bottle was on the floor; 6. Registered nurse I (RN I) did not follow manufacturer's instructions for disinfecting the glucometer (device used to check blood sugar levels); and 7. Nursing Assistant (NA) P did not do hand hygiene in between residents' assistance during lunch. These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During observation of lunch tray distribution on 8/12/2024 at 12:52 p.m., at the hallway, CNA N touched, and pushed the food cart then, parked it in front of Resident 42's room. CNA N touched and opened the food cart, took out Resident 42's lunch tray without performing hand hygiene. CNA N delivered the lunch tray and set it up for Resident 42. At 12:53 p.m., CNA N touched the food cart, pull it in front of Resident 189's room. CNA N took Resident 189's lunch tray without performing hand hygiene and served it to Resident 189. At 12:54 p.m., CNA N and CNA O touched, pushed the food cart, and parked in front of Resident 187's room. CNA N prepared coffee without performing hand hygiene. CNA O took Resident 187's lunch tray and served it to Resident 187 without performing hand hygiene. During an interview with CNA N on 8/12/2024 at 12:54 p.m., CNA N confirmed above observation and stated she should have performed hand hygiene before she touched Resident 42 and Resident 189's lunch tray. CNA N further stated she should have performed hand hygiene before she prepared coffee because food cart could be dirty. During an interview with CNA O on 8/12/2024 at 12:58 p.m., CNA O confirmed above observation and stated, I should have sanitized my hands before touching [Resident 187's] lunch tray. During an interview with infection preventionist (IP) on 8/16/2024 at 1:55 p.m., IP stated hand hygiene should be performed in between residents and after staff touched a possible dirty area. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, date revised October 2023, indicated, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. 2. During an observation on 8/12/2024 at 9:58 a.m., inside Resident 187's room, Resident 187 was awake but observed to be confused. Resident 187's nebulizer's mask was placed on top of Resident 187's bedside drawer. There was no date labeled in the nebulizer kit (tubing, mask, nebulizing chamber. During a concurrent observation and interview with registered nurse M (RN M) on 8/12/2024 at 11:05 a.m., inside Resident 187's room, RN M confirmed above observation. RN M stated nurses should have rinsed the nebulizer kit, airdried and stored inside a bag when not in used. RN M confirmed the nebulizer kit was undated and there was no nebulizer kit bag available in Resident 187's bed side drawer. RN M stated they should change the nebulizer kit once a week. During an interview with IP on 8/16/2024 at 1:55 p.m., IP stated the nebulizer kit should be changed once a week. IP further stated the nebulizer kit should be stored in a black mesh bag when not in used and the black mesh bag should be changed monthly. During an interview with director of nursing (DON) on 8/19/2024 at 2:13 p.m., DON stated the nebulizer kit should be changed once a week or as needed when visibly soiled. DON further stated the nebulizer kit should have been stored in a bag and the bag should be changed once a month. During a review of the facility's policy and procedure titled, Cleaning and Disinfecting, date revised May 2023, indicated, .for medical devices and equipment, standard cleaning and disinfection procedures for healthcare facilities are practiced as recommended in the cleaning and disinfecting policies. 46553 3. During a medication pass observation on 8/13/24 at 10:22 a.m., with LVN C in Resident 58's room, LVN C took Resident 58's BP with a BP apparatus. LVN C did not disinfect the BP apparatus before and after using it. During an interview with LVN C on 8/13/24 at 10:53 a.m., LVN C confirmed she did not disinfect the BP apparatus before and after using it on Resident 58. LVN C stated she was supposed to disinfect it with a disinfectant wipe before and after using it. During an interview with the infection preventionist (IP) on 8/19/24 at 10:51 a.m., the IP stated the nurses should disinfect the BP apparatus in between residents to prevent the spread of infection. A review of the facility's policy and procedure titled Cleaning and Disinfecting, revised 5/2023, indicated, Non-disposable medical equipment used for that resident is cleaned and disinfected according to the manufacturer's instruction and facility policies before use on another resident. 4. During an observation on 8/12/24 at 9:53 a.m., Resident 238's nebulizer mask and tubing were on the resident's bedside table. The mask and tubing were dated 7/2/24. During a concurrent observation and interview with LVN C on 8/12/24 at 1:01 p.m., LVN C verified Resident 238's nebulizer mask and tubing were outdated. LVN C stated the mask and tubing should be changed every week and as needed. LVN C stated these items should be stored in a plastic bag when not in use. 5. During an observation on 8/12/24 at 9:29 a.m., Resident 50 was lying in bed receiving oxygen. The humidifier bottle attached to the oxygen concentrator (a machine that supplies oxygen) was on the floor. During a concurrent observation and interview with LVN C on 8/12/24, at 10:41 a.m., LVN C verified Resident 50's oxygen humidifier bottle was on the floor. LVN C stated the humidifier bottle should not be on the floor. Review of the facility's policy and procedure titled Cleaning and Disinfecting, revised 5/2023, indicated, Standard cleaning and disinfection practices in accordance with the Centers for Disease Control and Prevention, measures are implemented when areas, material or equipment have likely been contaminated. 6. During a medication pass observation on 8/13/24 at 4:42 p.m., RN I removed a glucometer from the medication cart. RN I cleaned the glucometer with an alcohol swab and checked Resident 189's blood sugar. After checking Resident 189's blood sugar, RN I removed a wipe from a container with a lavender-colored top and wiped the glucometer. The container indicated the product was Micro Kill One Germicidal Alcohol Wipes. During an interview with RN I on 8/13/24 at 4:54 p.m., RN I confirmed she wiped the glucometer with an alcohol swab before using it and used Micro Kill One Germicidal Alcohol Wipes to disinfect the glucometer afterwards. During an interview with the IP on 8/19/24 at 10:54 a.m., the IP stated the glucometer should have been disinfected with an EPA-registered product, such as Clorox (a specific brand of disinfectant). The IP confirmed the facility did have Clorox wipes, which were in a container with a blue top. The manufacturer's instructions for the facility's glucometer, dated 10/2023, indicated to obtain a commercially available EPA-registered disinfectant or germicidal wipe and clean/disinfect the glucometer by following step-by-step instructions. 49345 7. During dining observation on 8/12/24 at 12:35 p.m., NA P applied clothing protector to five residents without hand hygiene in between. During dining observation at 8/12/24 at 12:46 p.m., NA P picked up something off the floor, put it on an empty tray and proceeded to clear out a table without doing hand hygiene. During an interview on 8/12/24 at 1:02 p.m. with NA P, NA P confirmed hand hygiene was not done in between assisting residents with clothing protector, and right after picking up something off the floor. NA P stated hand hygiene should have been done in both instances. A review of facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene revised October 2023, the P&P indicated, .Hand hygiene is indicated: a. immediately before touching a resident; .c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment;

Based on observation, interview and record review, the facility failed to ensure dignity and privacy was upheld for 1 of 2 sampled Residents (Resident 12) when Resident 12's Suprapubic catheter [SP Catheter, a device inserted into your bladder (organ that collects urine) to drain urine if you cannot urinate on your own made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine] drain bag was left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 12. Findings: During a review of Resident 12's Facesheet (FS, a document that gives a resident's information at a quick glance), undated, the FS indicated, admission diagnoses include End Stage Renal Disease (ESRD, condition in which the kidneys lose the ability to remove waste and balance fluids). During a review of Resident 12's physician order dated, 7/8/2024 indicated, an order for a Suprapubic Catheter due to diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). During an observation on 08/13/24 at 04:18 p.m., in Resident 12's Room. Resident 12 was lying in bed, urine bag hanging on the right inside of resident bed, yellow colored urine is visible from drainage bag, was uncovered. Resident stated, he just came back few hours ago from dialysis. During an interview with Certified Nursing Assistant B (CNA B) on 08/13/24, at 04:32 p.m., CNA B stated, Resident 12's drainage bag was not covered. CNA B stated, we need the thing to always cover the urinary drainage bag. During an interview with Licensed Vocational Nurse A (LVN) on 08/13/24, at 04:35 p.m., LVN A stated, Resident 12's drainage bag should not be left uncovered. LVN A stated, urinary drainage bag should have covered with privacy/dignity bag all the time. During an interview with Director of Nursing (DON) on 08/19/24, at 03:00 p.m., DON stated, Urinary drainage bag should be always covered with privacy or dignity bag. Inside or outside the facility. During a review of facility's policy and procedure (P&P) titled, Dignity revised February 2023, the P&P indicated, Residents are treated with dignity and respect at all times.

Based on interview and record review, the facility failed to obtain an informed consent for one of two sampled residents (Resident 44), for the medication lorazepam (medication used for anxiety). This deficient practice had the potential for the resident or the representative not to be informed of the risks, benefits, and alternatives of the given treatment (medication) and may lead to the inability to exercise the rights to a preferred choice or alternative treatment. Findings: A record review of Resident 44's clinical record, indicated medical diagnoses including Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Catatonic Schizophrenia (a rare and severe mental disorder that's characterized by extreme changes in movement, behavior, and communication). A record review of Resident 44's Physician Orders indicated an order dated 7/4/2023 for Lorazepam, give 1 milligram (mg, unit of measurement) by mouth three times a day for Catatonic Schizophrenia, started on 7/4/2023. A review of Resident 44's Informed Consent form for Ativan (other name for Lorazepam) 1 mg indicated, a physician's signature dated 7/10/2023 and a signature of licensed nurse verification of informed consent being obtained by physician dated 7/4/2023. It also indicated that consent was obtained by phone. However, it neither indicated if consent was given by Resident 44 or by a surrogate decision maker. During concurrent interview and record review on 8/14/2024 at 11:42 a.m. with Director of Nursing (DON), DON confirmed there was no name written on the Informed Consent form for Ativan from whom consent was obtained. A review of facility's policy and procedure (P&P) titled Psychotropic Medication Use/Informed Consent dated March 2004, the P&P indicated, Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative .If the resident or resident's representative cannot sign the form, a licensed nurse can sign the form and document the name of the person who gave the consent and the date.

Based on interview and record review, the facility failed to report a suspected allegation of resident abuse in a timely manner for two of two residents (Residents 196 and 24) when: 1. The alleged missing money of Resident 196 was not reported to the California Department of Public Health (CDPH, a state department responsible for public health in California), Adult Protective Services (APS) and Office of the Long Term Care Ombudsman ( LTCO, an advocate for residents of nursing homes, assisted living facilities, and other residential care communities) when it was first reported to the Social Services Director (SSD) on 11/18/2022; and 2. The alleged Resident/Patient/Client Abuse (Resident to Resident) incident on 12/31/22 was not reported to CDPH , Ombudsman , and Law Enforcement when the incident was first reported on 12/31/22 not until 1/3/23. When Resident 24 randomly struck another Resident on the face at the hallway while alleged victim was self-propelling in wheelchair. These failures had the potential to delay identification and implementation of appropriate corrective action and put the residents at risk for abuse. Findings: 1. Review of Resident 196's clinical records titled, Admission Record, dated August 19, 2024, indicated Resident 196 was admitted to the facility on [DATE] with diagnoses including cerebral aneurysm (also known as brain aneurysm, a weak spot in the brain's arterial circulation that balloons and fills with blood), nonruptured, acute embolism (an obstruction of an artery, typically by a clot of blood or an air bubble) and thrombosis (clotting of the blood in a part of the circulatory system) of unspecified deep veins of right lower extremity, and bilateral (both) primary osteoarthritis [type of arthritis (painful inflammation and stiffness of the joints) more common in older people having joint pain, and after rest or inactivity, stiffness for a short period of time] of knee. Further review indicated Resident 196 was discharged on [DATE]. Review of Resident 196's quarterly minimum data set (MDS, an assessment tool), dated 12/21/2022, indicated Resident 196's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]; a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact) score was 12. Review of Resident 196's SSD's note dated 11/18/2022, indicated, the SSD met with Resident 196 to hear a concern. Further review indicated, Res (resident) reported missing money that were brought to her by her friend .res asked to file police report .SSD educated patient about financial responsibility by choosing to manage her own finances. Review of Resident 196's SSD's note, dated 12/13/2022, indicated the SSD met with Resident 196 to follow up on LTCO's visit on 12/13/2022. The LTCO instructed SSD to file the SOC 342 (a report of suspected dependent adult/elder financial abuse) regarding the reported lost money on 11/18/2022. Further review indicated, Resident stated during the interview that she does not remember the exact date of the incident, but she remembers she had reported it to the Social Worker. Translator asked the resident if the lost money she had reported to the Ombudsman was the same report she had made previously to the Social Worker and she said yes .Resident reports she has no idea how her money went missing and that it was about $345.00 Review of the Resident 196's interdisciplinary team's [IDT, (a group of health care professionals from diverse fields who work toward a common goal for residents)] review note, dated 12/14/2022, indicated, IDT met to review resident grievance report and new report filed for possible misappropriation of funds per ombudsman request .Resident states that she left her money in an envelope on her bedside table when she went to shower and noticed later that it was gone. The new filed report for possible misappropriation of funds was the same reported by Resident 196 to SSD on 11/18/2022. During an interview with SSD on 8/19/2024 at 11:32 a.m., SSD stated any reported lost properties should be reported right away to CDPH, LTCO and police. During an interview with director of nursing (DON) on 8/19/2024 at 2:22 p.m., DON confirmed the reported Resident 196's lost money on 11/18/2024 and 12/13/2022 was the same incident. DON stated she was not aware that the Resident 196's reported lost money was not reported to CDPH and LTCO on 11/18/2022. DON further stated it should have been reported to CDPH and LTCO on 11/18/2022. During an interview with the administrator (ADM) on 8/19/2024 at 4:15 p.m., ADM stated she couldn't find any documentation why Resident 196's lost money was not reported on 11/18/2022 to CDPH and LTCO. During a review of the facility's policy and procedure titled, Abuse Investigation and Reporting, date revised July 2017, indicated, Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24 hours) if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. 46553 2. Review of Resident 24's clinical record indicated she was initially admitted on [DATE] and had the diagnoses Dementia (term for loss of memory, language, problem -solving and other thinking abilities that are severe enough to interfere with daily life) unspecified severity with other behavioral disturbance ; major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), anxiety disorder (characterized by feeling of worry, anxiety, or fear), Epilepsy (disorder in which nerve cell activity in the brain is disturbed , causing seizure). Review of Resident 24's quarterly BIMS score dated 5/29/24, was 7 (0-7 indicates severe cognitive impairment). During a review of Confidential Report-Not Subject to Public Disclosure -SOC 341 faxed by the facility to the Department dated 1/3/23 which indicated Resident randomly struck another Resident in the face in station 5 hallway while he was self-propelling in wheelchair. During a concurrent interview and record review on 8/19/24 at 3:15 p.m., with Director of Nursing (DON), stated she remember the incident and was reported late to her, it should be reported ASAP or within 2 hours to the appropriate agency. DON further stated monitoring within 72 hours. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated revised July 2021, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown source(abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigation s will also be reported. Reporting 2. All alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involve abuse OR has resulted in serious bodily injury, or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan to include instructions on care of oxygen use for one of three residents (Resident 190). This failure resulted in improper level of oxygen administration for Resident 190 and had the potential to result in oxygen toxicity such as lung damage. Findings: Review of Resident 190's Admission Record indicated, Resident 190 was admitted to the facility on [DATE] with diagnoses including displaced (the pieces of the bone moved so much that a gap formed around the broken bone) supracondylar fracture of left femur (when the thigh bone is broken at the knee), morbid obesity (a person weighing more than 100 pounds over the ideal weight for men and 80 pounds for women) and obstructive sleep apnea (a common sleep disorder that causes breathing to pause during sleep due to a blocked or narrowed airway). Review of Resident 190's physician's order dated 8/2/2024, indicated, Oxygen @ [at] 0.5 liter/min [liter per minute] via [thru] Nasal Cannula [NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration] at bedtime, as needed. Review or Resident 190's physician order dated 8/5/2024, indicated, the order of oxygen at 0.5 liter/min was changed to 1 liter/min at bedtime, as needed. During an observation on 8/12/2024 at 10:25 a.m., inside Resident 190's room, Resident 190 was asleep, the oxygen's NC was in placed and the level of oxygen administration was at 1.5 liter/min. During a concurrent interview with registered nurse D (RN D) and record review on 8/14/2024 at 1:49 p.m., RN D confirmed Resident 190 had an oxygen order since admission on 8/2/2024. RN D stated there should be a baseline care plan for Resident 190's oxygen use. During an interview with minimum data set nurse (MDSN) on 8/15/2024 at 9:33 a.m. MDSN stated admission nurses should initiate the baseline care plan after they completed their assessment. MDSN further stated the interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) should review the baseline care plan with the resident or resident's responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action). During a concurrent interview with MDSN and record review on 8/15/2024 at 9:39 a.m., MDSN reviewed Resident 190's baseline care plans. MDSN confirmed there was no baseline care plan regarding the oxygen use of Resident 190. During an interview with director of nursing (DON) on 8/19/2024 at 2:12 p.m., DON stated the baseline care plan for Resident 190's oxygen use should have been developed within 72 hours of admission since oxygen use was ordered upon Resident 190's admission. During a review of the Long Term Care Solutions postings titled, Baseline Care Plan Requirements Outlined by CMS [Centers for Medicare and Medicaid Services], date posted 5/14/2024, indicated, Long term care facilities must develop and implement a baseline care plan for each resident within 48 hours of admission .the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, including but not limited to: initial goals based on admission orders, physician orders .

Based on observation, interview, and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) was provided for three of three sampled residents (Residents 190, 18 and 36) when: 1.Resident 190's physician'a order for oxygen administration was not followed and the Oxygen in Use sign was not visible to all passersby (staff, residents and visitors); 2.Resident 18's physician's order for oxygen administration was not followed; and 3.Resident 36's physician's order for oxygen administration was not followed. These failures had the potential to result in complications related to improper treatment while receiving O2 therapy. Findings: 1a. Review of Resident 190's Admission Record indicated, Resident 190 was admitted to the facility on [DATE] with diagnoses including displaced (the pieces of the bone moved so much that a gap formed around the broken bone) supracondylar fracture of left femur (when the thigh bone is broken at the knee), morbid obesity (a person weighing more than 100 pounds over the ideal weight for men and 80 pounds for women) and obstructive sleep apnea (a common sleep disorder that causes breathing to pause during sleep due to a blocked or narrowed airway). Review or Resident 190's physician's order dated 8/5/2024, indicated, the order of oxygen at 0.5 liter/min was changed to 1 liter/min at bedtime, as needed. During an observation on 8/12/2024 at 10:25 a.m., inside Resident 190's room, Resident 190 was asleep with O2 at 1.5 liter/min (liter per minute) via (thru) nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration). During a concurrent interview with registered nurse D (RN D) and record review on 8/14/2024 at 1:46 p.m., RN D reviewed Resident 190's oxygen order. RN D confirmed there was an order for oxygen administration at 1 liter/min at bedtime, and as needed. During another concurrent interview with RN D and review on 8/14/2024 at 2:00 p.m., RN D reviewed Resident 190's level of oxygen administration taken on 8/12/2024. RN D confirmed Resident 190's level of oxygen administration on 8/12/2024 was at 1.5 liter/min. RN D stated nurses should follow the level of oxygen administration as ordered by the physician. 1b. During a concurrent observation and interview with registered nurse M (RN M) on 8/12/2024 at 11:16 a.m., outside Resident 190's room, in front of the door, the Oxygen in use sign was observed posted under the Enhanced Barrier Precaution signage. RN M confirmed above observation. RN M stated the Oxygen in use sign should be posted visible to all staff, visitors, and residents. During an interview with director of nursing (DON) on 8/19/2024 at 2:07 p.m., DON stated the Oxygen in Use posting should be visible and usually posted by the resident's door. 2.Review of Resident 18's Admission Record indicated, Resident 18 was admitted to the facility with diagnoses including congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), acute (present or experienced in a severe degree) and chronic (persisting for a long time or constantly recurring) respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (occurs when oxygen level in the body organs are low), encounter palliative care (a type of medical care that helps people with serious illnesses and their families improve their quality of life), and obstructive sleep apnea. Review of Resident 18's physician's order dated 8/9/2024, indicated, Oxygen @4 liter/min via Nasal Cannula continuously every shift. During an observation on 8/12/2024 at 10:30 a.m., inside Resident 18's room, Resident 18 was asleep and was on oxygen at 4.5 liter/min via NC. During a concurrent interview with RN D and record review on 8/14/2024 at 1:50 p.m., RN D reviewed Resident 18's oxygen order. RN D confirmed Resident 18's oxygen order was supposed to be at 4 liter/min. At 1:54 p.m., RN D reviewed the picture of Resident 18's oxygen level of administration taken on 8/12/2024. RN D confirmed Resident 18's oxygen administration on 8/12/2024 was at 4.5 liter/min. 3. Review of Resident 36's Admission Record indicated, Resident 36 was admitted to the facility with diagnoses including cerebrovascular disease (referred to as stroke), chronic congestive heart failure, chronic obstructive pulmonary disease (COPD - a long lasting lung disease), and morbid obesity. Review of Resident 36's physician's order dated 8/15/2024, indicated, an order for oxygen use at 3 liter/min as needed only for shortness of breath. During an observation on 8/12/2024 at 11:00 a.m., inside Resident 36's room, Resident 36 was asleep and had an oxygen in placed at 3.5 liter/min via NC. During a concurrent interview with RN D and record review on 8/14/2024 at 1:51 p.m., RN D reviewed Resident 36's oxygen order. RN D confirmed Resident 36's oxygen order should be at 3 liter/min. During a concurrent observation and interview with RN D on 8/14/2024 at 1:56 p.m., inside Resident 36's room, Resident 36 was seated at the edge of his bed with oxygen in placed at 3.5 liter/min via NC. RN D confirmed above observation and stated nurses should follow the level of oxygen administration ordered by the physician. During an interview with minimum data set nurse (MDSN) on 8/15/2024 at 9:50 a.m., MDSN stated nurses should follow the doctor's order and they should check the order first prior to administration of oxygen. During an interview with DON on 8/19/2024 at 2:07 p.m., DON stated nurses should check doctor's order first prior to administration of oxygen whether the order was as needed or a routine order. During a review of the facility's policy and procedure titled, Oxygen Administration, date revised February 2024, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or the facility protocol for oxygen administration .Place an Oxygen in Use sign in a designated place on or over the resident's bed.

Based on interview and record review, the facility failed to ensure staff followed the Policy and Procedure (P&P) titled Lifting machine, using a mechanical when transferring residents from the bed to a chair for two out of three residents (Residents 1 and 2). A mechanical lift is a metal assistive device with a U-shaped base, an overhead bar and a sling that work together to lift, reposition, and lower a resident into a chair or a bed. On 6/23/2023, Resident 1 was being transferred with a mechanical lift from her bed to a shower chair by one staff member (Certified Nursing Assistant (CNA) A). During the transfer, one of the straps from the sling became disconnected, which resulted in Resident 1 falling out of the sling onto the floor. Resident 1 sustained head injuries and lacerations to the left arm, requiring an emergency room transfer and admission to the hospital. Resident 2 also required a mechanical lift transfer. During an interview on 6/28/2023, Resident 2 stated that approximately 2-3 times a month, only one staff member uses a mechanical lift to transfer her from the bed to the chair. The failure to ensure two staff members were present during mechanical lift transfers resulted in Resident 1 to fall, sustained head injuries and lacerations to the left arm, requiring an emergency room transfer and admission to the hospital. This failed practice also had the potential for other residents that use the lift to fall. Findings: On 6/26/2023 at 8:42 a.m., the facility notified the California Department of Public Health that on 6/23/2023, at approximately 3:35 p.m., Resident 1 sustained lacerations to her left forearm, laceration to the bottom of her lip, bruising to her right arm/elbow and crepitus (grating sound) to an area above her eyebrow after falling from a mechanical lift to the ground. Clinical record review for Resident 1 was conducted on 6/28/2023. Review of Resident 1's Emergency Department Provider Report, dated 6/23/2023, indicated Resident 1 was brought to the emergency room after falling from a mechanical lift at the skilled nursing facility. The resident groaned in discomfort. Examination of her head indicated a laceration to her right forehead region requiring suture repairs, a right eye hematoma (bleeding around the eye), abrasion to the lips and dried blood in her mouth. Her left lower leg had a small hematoma on the front of her shin. A computerized tomography (CT scan - combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside the body. CT scan images provide more-detailed information than plain X-rays do.) indicated Resident 1 also sustained a right-sided subdural hemorrhage (bleeding in the brain). Review of Resident 1's hospital Neurosurgery (medical discipline that specializes in surgery performed on the nervous system, especially the brain and spinal cord) Consultation Note, dated 6/23/2023, indicated no surgery would be performed and that the subdural hematoma was potentially life-threatening. The family requested comfort care only (symptom control, pain relief, and quality of life). Review of the facility's P&P, Lifting machine, using a mechanical (revised 7/2017) indicated, . at least two nursing assistants are needed to safely move a resident with a mechanical lift. Steps in the procedure (using the lift) included, .to make sure the straps to the sling bar are securely attached to the clips and that it is properly balanced, before the resident is lifted, double check the security of the sling attachment and lift the resident two inches from the surface (bed) to check the stability of the attachments, the fit of the sling, and the weight distribution. Review of the manufacturer's manual titled Manual/electric Portable Patient Lift Owner's Installation and Operating Instructions, dated 2001, showed warning: when elevated a few inches off the surface of the bed and before moving the resident, check again to make sure that the sling is properly connected to the hooks of the swivel bar. Review of the facility's Unusual Occurrence Initial Report, dated 6/24/2023, indicated, on 6/23/2023 at approximately 3:35 p.m., Licensed Vocational Nurse (LVN) C was called to Resident 1's room after it was reported Resident 1 had fallen. The nurse found Resident 1 on the floor laying on her right side on top of one of the Hoyer legs with CNA A by her side. Resident 1 sustained lacerations to her left forearm, laceration to her bottom lip, bruising to her right arm/elbow and crepitus (grating sound) was noted to her forehead above her eyebrow. The maintenance staff checked the mechanical lift and sling and noted both were functioning properly. Review of Resident 1's Unusual Occurrence Final Report indicated that, on 6/23/2023 at approximately 3:35 p.m., LVN C was called into Resident 1's room by a CNA. LVN C stated she saw Resident 1 lying on the ground and there was blood on the floor. LVN C yelled for additional staff to help with Resident 1. CNA A stated she went to transfer Resident 1 with the mechanical lift and a sling. She placed the sling under the resident and hooked the straps to the machine. CNA A stated she lifted Resident 1 off the bed (with the lift) and pulled the machine towards the right to place Resident 1 into a shower chair, when the resident started to fall towards her right side. CNA A's statement included, I was by myself transferring the patient (resident). I am aware that this is not the proper protocol. The Director of Nurses (DON) documented, the facility concluded that the resident fell from the Hoyer lift (mechanical lift) due to CNA error. Review of Resident 1's Admission Record face sheet (summary overview of the resident's important information) indicated she was admitted to the facility with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or inability to move on one side of the body) affecting her right-side (arm and leg), right-hand contracture (deformity) and unspecified dementia (decreased memory and thinking capabilities). Review of Resident 1's Minimum Data Set (MDS-an assessment tool) dated 4/12/2023, indicated she required extensive assistance from two staff members for transfers. Her balance during transfers indicated she was not steady and required stabilization with staff for assistance. Review of Resident 1's care plan to address her activities of daily living (ADL) care indicated on 8/12/2020, she was total dependent with transfers via a mechanical lift, which requires two people. Review of Resident 1's Progress Note, dated 6/23/2023 at 3:35 p.m., indicated Resident 1 sustained lacerations to her left forearm (approximately 8 centimeters (cm)) and to the bottom of her lip (approximately 3 cm), bruising to her right arm/elbow and crepitus to her forehead above her eyebrow. Review of Resident 1's Post-Fall Review form, dated 6/23/2023 at 3:50 p.m., indicated the Interdisciplinary Department Team (IDT) determined the root cause of the fall to be when the resident fell from the mechanical lift, the resident had no trunk control and no ability to brace herself due to hemiparesis and hemiplegia (paralysis) to her right side coupled with contractures (deformity). Review of CNA A's Performance Skill Check lists show she had met her return demonstration on the proper transferring and safety of a mechanical lift dated 12/14/2022 and again on 3/20/2023. Review of the Maintenance Safety Inspection Checklists for the two mechanical lifts, dated 6/7/2023, indicated the lifts were inspected and in proper working order. Another checklist dated 6/23/2023, was performed following Resident 1's incident. Both lifts were inspected and were in proper working order. An interview was conducted with the Director of Nursing (DON) on 6/28/2023 at 10:25 a.m. She stated Resident 1 was not able to make her needs known and her right arm and leg were contracted. The DON stated, on 6/23/2023 at approximately 3:30 p.m., she was notified of Resident 1 being on the floor. She stated when she entered Resident 1's room, only CNA A was in the room. The DON stated the mechanical lift was upright and the sling's straps were still attached except the front right strap (near the foot). She stated Resident 1 was on the floor, her torso was on top of the leg of the mechanical lift and the resident's left hand was grasping the lift. The DON stated Resident 1 was moderately bleeding above her right eyebrow, nose, and mouth. She stated further assessment of Resident 1 indicated the resident had a skin tear to her left forearm, bruises to her right elbow and her lip was bleeding. The DON stated she assessed the sling and there were no visible signs of rips or tears on the sling/straps. She confirmed two staff members should be transferring a resident when a mechanical lift was to be used. On 6/28/2023 at 12:05 p.m., an interview was conducted with the Maintenance Director. He stated he checked the mechanical lifts monthly and the lifts are in proper functioning order. The Maintenance Director stated he performed a routine maintenance check on the mechanical lifts on 6/7/2023, and the lift was functioning properly. He was asked to recheck the lifts on 6/23/2023, after Resident 1 had fallen during a transfer and the lift and slings were in good working order. During an interview on 6/28/2023 at 1:45 p.m., CNA E stated Resident 1 was nonverbal and unable to make her needs known. She stated Resident 1 was unable to stand and required the use of a mechanical lift during transfers. CNA E stated two staff are required to assist when using a mechanical lift. On 6/28/2023 at 4:40 p.m., a telephone interview was conducted with CNA A. She stated Resident 1 was nonverbal and could move one arm, but her legs were contracted. She stated she was aware two staff members are needed to use the mechanical lift and she had previously asked another CNA to help her transfer Resident 1 with the mechanical lift, but the CNA never came back into the room, so she transferred the resident by herself. CNA A stated when she started to move the mechanical lift, the left strap came off and Resident 1 fell out of the sling. On 6/28/2023 at 6:34 p.m., a telephone interview was conducted with LVN C. She stated Resident 1 was nonverbal, moans and cries. LVN C continued to state Resident 1's right arm was flaccid (limp), and her left leg was contracted. She stated, on 6/23/2023 at approximately 3:30 p.m., CNA B came to the nurses' station and notified her that a resident was on the floor. LVN C stated when she entered Resident 1's room, she saw Resident 1 on the floor on top of the mechanical lift and a lot of blood was on the floor. She stated Resident 1's head sustained a laceration to the right side of her head. LVN C stated the sling was still attached to the mechanical lift; however, one of the straps was not hooked. She stated two staff members are needed when a resident was to be transferred using a mechanical lift. A telephone interview was conducted on 6/28/2023 at 6:45 p.m. with CNA B. She stated Resident 1 was nonverbal and unable to move her extremities. CNA B stated two staff members are needed for a resident to be transferred using a mechanical lift. Clinical record review for Resident 2 was conducted on 6/28/2023. Resident 2 was admitted to the facility with diagnoses including lack of coordination. Her MDS dated [DATE] indicated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact). Resident 2 required extensive assistance of two staff members for transferring. Review of Resident 2's care plan problem to address her performance deficit related to muscular impairment, dated 5/31/2017, indicated she required two staff members to transfer via a mechanical lift. On 6/28/2023 at 2:30 p.m., an interview was conducted with Resident 2. She confirmed she requires a mechanical lift to transfer from the bed to her wheelchair. Resident 2 stated sometimes there is only one staff member doing the transfer because they cannot find any other staff member to help them. She stated this usually happens two to three times a month.

Based on interview and record review, the facility failed to provide routine medications to meet the needs of residents for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 did not receive his Keppra (generic name: levetiracetam, a medication to treat seizure disorder [a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness]) for 48 hours due to the medication not being available. The nursing staff did not notify the physician when the medication was not available to give, nor did they follow up with the pharmacy to receive the medication timely. The failure resulted in Resident 1 experiencing multiple episodes of seizures, became unresponsive while being transferred to Emergency Department (ED), and was hospitalized for treatment. 2. Resident 2 did not receive her Keppra due to medication not available x 1 dose. This failure placed Resident 2 at risk to experience seizures, falls, and injuries related to seizures. Findings: According to an online publication titled Missed Medicines as a Seizure Trigger by the Epilepsy Foundation, it indicated, Missing doses of seizure medicine is the most common cause of breakthrough seizures. Missed medicines can trigger seizures in people with both well-controlled and poorly controlled epilepsy. Seizures can happen more often than normal, be more intense or develop into long seizures called status epilepticus. Status epilepticus is a medical emergency and can lead to death if the seizures aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels. (https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines; accessed 3/22/23) 1. On 3/17/23, a review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including multiple sclerosis (a disabling disease of the brain and spinal cord where immune system attacks the protective sheath [myelin] that covers nerve fibers and causes communication problems between your brain and the rest of your body), muscle weakness, abnormality of gait and mobility, and epilepsy (also called seizure disorder). A review of Resident 1's Minimum Data Set (MDS, a care area assessment and screening tool), dated 2/1/23, indicated he had a BIMS score of 12 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated his cognitive condition was moderately impaired. Further review of Resident 1's clinical record indicated a physician's order, dated 7/28/22, for Keppra 500 milligrams (mg, unit of measurement), Give 1,000 mg by mouth two times daily for seizures. The facility scheduled it to be given daily at 9 a.m. and 5 p.m. Resident 1 was also receiving Dilantin (anti-seizure medication) 100 mg, 2 capsules in the morning and 2 capsules in the evening, starting 1/29/23. A review of Resident 1's March 2023 medication administration record (MAR) indicated Keppra tablets were not administered for 48 hours, on 3/3/23 at 9 a.m. and 5 p.m. and 3/4/23 at 9 a.m. and 5 p.m., as follows: a. On 3/3/23: 9 a.m. entry: Code 10 entered by registered nurse (RN) A; 5 p.m. entry: Code 10 entered by RN B b. On 3/4/23: 9 a.m. entry: Code 10 entered by licensed vocational nurse (LVN) C; 5 p.m. entry: Code 10 entered by RN B The MAR's Chart Code indicated each number code had a different meaning, such as 1 = resident refused, 2 = resident not available. The 10 code meant Other (specify). A review of the corresponding nursing progress notes indicated the following: a. 3/3/23 at 9:21 a.m., RN A wrote Keppra Tablet 500 mg .[dosing and frequency] . on order b. 3/3/23 at 4:17 p.m., RN B wrote: Keppra Tablet 500 mg . on order c. 3/4/23 at 10 a.m., LVN C wrote: Keppra Tablet 500 mg . on order d. 3/4/23 at 4:28 p.m., RN B wrote: Keppra Tablet 500 mg . on order Further review of Resident 1's clinical record indicated the nursing progress notes, documented by RN B on 3/5/23 at 2:20 a.m., indicating: 3/4/23 at 2330, Resident started having seizures 5x [meaning 5 times] lasting more than 3 minutes. Turned resident on his side to avoid aspiration [accidental breathing in of food or fluid into the lungs]. VS [vital signs] taken. Afebrile [not feverish]. MD [physician] notified with order to send to ER [emergency room ] for further eval[uation] . A review of the 3/5/23 Emergency Medical Services (EMS) Prehospital Care Report w/o [without] Attachments, provided by the hospital, indicated: Responded to seizures. Upon arrival pt [patient] found lying left lateral position . postictal [period of time immediately following a seizure] . Per staff pt has been witnessed to have multiple seizures starting at approx. 23:45 tonight. Per staff pt has a history of seizures . Pt is noted to have shaking of extremities and pt reports impending seizure. Pt is noted to have a full-body generalized seizure lasting approx. 2 minutes. Pt administered 2.5 mg Versed [medication to treat seizures] IM [intramuscularly, meaning deep muscle injection] . Pt is noted to be unresponsive . During transport pt remained altered and unstable. At hospital pt moved to Emergency Department . A review of the acute care hospital's History and Physical (document that provides concise information about a patient's history and exam findings at the time of admission), date of service 3/5/23 at 4:55 a.m., indicated the hospital received Resident 1 for Chief Complaint of seizure. Under History of Present Illness (HPI), a hospital's physician wrote, [Age of resident] year-old male, institutionalized due to multiple sclerosis, presents with seizures. He has a longstanding seizure disorder for which he takes Dilantin and Keppra. The patient had 2 seizures in the nursing home for which 911 was called. He seized again for paramedics and they gave him intramuscular Versed at least twice. Seizure. When the patient got to the emergency room . However he was postictal and unresponsive. Dilantin level was subtherapeutic [lower than normal range] and it turns out the nursing home ran out of Keppra 48 hours ago. Under Plan, the H&P indicated, [Age] year-old male . presents with seizures 48 hours after running out of his Keppra, also with a subtherapeutic Dilantin level. He will be admitted to [Name of Hospital] for loading of Dilantin and Keppra and resumption of both medications orally . A review of the ED Physician Documentation, dated 3/5/23, indicated Resident 1 arrived on 3/5/23 at 1:06 a.m. via EMS. The ED physician wrote, on 3/5/23 at 1:11 a.m., The patient presents with 'More seizures' tonight per nursing home staff . He was found postictal by EMS and then said he felt like he was when have a seizure and had a full-blown seizure with O2 [oxygen] as low as 75% [normal: 95% - 100%] at the end. Was given 2.5 mg of Versed . and 3/5 4:00 [a.m.] Awaiting: History from the nursing home is helpful . it turns out they have not had Keppra since the 2nd so the patient has missed 48 hours of Keppra. They do not have any still. This is clearly at least contributing to why he is seizing. I will have to admit him since I can send him back to place the does not have the medicine to care for him. A review of the ED Nurse Documentation, dated 3/5/23 at 3:58 a.m., indicated: Contacted Watsonville Nursing Center, spoke with [name of nurse] . It was also reported to this RN by [name of nurse] that the patient has not had any of his scheduled Keppra doses (patient is prescribed 1000mg Keppra BID [meaning twice daily] for seizure prevention), reported to RN that the last dose patient received was 3/2/23 evening, and has not had any dosed since then. It was reported that the facility had ran out and they were waiting for the pharmacy to deliver more . Resident 1's clinical record indicated the resident was admitted to the hospital on 3/5/23 at 4:30 a.m., and discharged on [DATE] at 10:45 a.m. The nursing progress notes, dated 3/6/23, indicated he was readmitted to the facility on [DATE] at approximately 2:50 p.m. A review of the hospital's Discharge Summary, dated 3/6/23, indicated the following under Final Diagnoses: Epileptic seizure related to external causes, not intractable [untreatable], without status epilepticus [prolonged seizure lasting longer than 5 minutes or when seizures occur close together and the person doesn't recover between seizures] . Uses less medication than prescribed . Patient's unintentional underdosing of medication regimen. The History Course in the Discharge Summary indicated, .male with multiple sclerosis . Apparently they ran out of his seizure medications at the nursing facility. Seizures. Patient was admitted and received a loading dose [large dose of a medicine used to ensure a quick therapeutic response] of Dilantin and Keppra. By hospital day 2. The patient was alert and oriented and mentating at baseline. A review of the Medical Provider progress notes, written by Resident 1's attending physician (Physician A) on 3/7/23 at 9:56 p.m., indicated: Seizure d/o [disorder] . Unfortunately was out of Keppra x 2 days and had recurrent seizures. hospitalized and dilantin dose increased again. Discussed care with DON [director of nursing] re: missed medications . For now continue current doses of Dilantin and Keppra, may try to reduce Dilantin again in future. During an interview with Resident 1 on 3/17/23 at 1:27 p.m., Resident 1 stated he had been on Dilantin and Keppra for many months for seizure disorder. He stated the day he had the seizures he was very confused and did not know what was going on. He stated prior to that the nursing staff had told him they ran out of Keppra and were waiting for the pharmacy to deliver. He stated he told them he needed the medication, but they said they were still waiting for it to come. He stated he was not aware of what went on when he was at the hospital, but they put him back on the medications and sent him back. Resident 1 stated he was aware he had the seizures because he was missing a few days of Keppra. During an interview with RN A on 3/17/23 at 2:01 p.m., she confirmed she was the morning shift nurse on 3/3/23 and coded a 10 on the MAR for Resident 1's Keppra administration. She stated Code 10 meant the medication was not available, and she ordered it through the facility's computerized system. She stated she informed Resident 1 the medication was not available. She continued, I knew he had gotten it the day prior; he was stable, they didn't have the med. RN A stated she was not aware the medication was available in the facility's automatic dispensing cabinet (ADC, an automated machine where medications are stored and electronically tracked) so she could get it from there and did not inform the doctor. She confirmed she should have informed the doctor when Keppra was not available to give to the resident. RN A confirmed she was aware Resident 1 was hospitalized for seizures due to missing his Keppra when she was counseled by the DON on 3/10/23. On 3/17/23 at 2:16 p.m., the DON provided an inventory list of medications available in the facility's ADC. The list indicated the ADC contained 115 different medications including levetiracetam (Keppra) 250 mg tablets. During a telephone interview with the Pharmacist on 3/17/23 at 2:18 p.m., she stated the facility staff requested a refill for Keppra on 3/3/23 at 9:21 a.m. (this is consistent with the interview with RN A above) but it was not delivered until 3/5/23 at 4:13 p.m. (2 days later). She stated most of the refill requests were processed and delivered from a sister pharmacy in southern California, that was why it took two days to deliver. She stated, We ask [facilities] for a few days to process refills. If they need medications urgently, they give us a call to [name of pharmacy] to send with the next run. The Pharmacist reviewed the pharmacy dispensing records and stated a 30-day supply of Keppra was delivered on 1/3/23 and on 3/5/23; there were no request for and delivery in February 2023. During a concurrent interview and record review with RN B on 3/17/23 at 3:09 p.m., she stated she coded a 10 on the Keppra 5 p.m. administrations on 3/3 and 3/4/23. When asked what Code 10 meant, RN B stated, I think that was when we ran out of Keppra. She stated, I was not able to call the doctor on those days the medication was not available and could not recall whether she called the pharmacy to follow up. She stated she informed Resident 1 that they were waiting for the pharmacy to deliver. RN B reviewed the March 2023 MAR and confirmed she administered the last dose at 5 p.m. on 3/2/23, but she stated she could not remember if she ordered it. She confirmed when the medication supply was running low, the nursing staff was to re-order it 3 to 5 days ahead to allow time for the pharmacy to deliver. She also added that she was not aware the Keppra tablets were available in the ADC. RN B reviewed Resident 1's clinical record and confirmed both times, on 3/3 and 3/4/23 at 5 p.m. that she only documented on order in the nursing progress notes. During the interview above, RN B stated on the day of event, the aide called her about Resident 1 having a seizure. They ran to the resident's room, found him seizing, had him turned to his side, and probed a pillow on the wall to stop him from hitting the wall. She stated it lasted about 1 to 2 minutes, then it stopped, and he started seizing again that lasted more than 2 minutes. She called the doctor and asked to have him sent to the ER. RN B stated she was made aware Resident 1 experienced seizures because of the missing Keppra when she was counseled by the DON later that week. During a concurrent interview and record review with the DON on 3/17/23 at 3:50 p.m., the DON explained Resident 1 experienced the seizures on the weekend when he was out of Keppra for 2 days. She stated she was not aware he missed 4 doses. She stated, The nurses notified me that he went to the hospital, but I was not aware about the Keppra until I reviewed his re-admission papers the next day [after the resident returned] that's when I noticed. The DON explained, [RN A] re-ordered the Keppra on 3/3 [March 3rd] but the pharmacy delivered it on 3/5 by the time the resident was already in the hospital. The DON stated when the nursing staff ran out of the medication, they should be checking the ADC list to see if the medication is available in it; and if not, call the pharmacy to get it satellited (special delivery by a nearby pharmacy). She continued, If that's not an option, to notify the doctor to get another medication [for the resident]. She stated, They could have called the doctor to increase his Dilantin while waiting for Keppra. The DON reviewed Resident 1's clinical record and confirmed there were no documented evidence the nursing staff calling the physician or the pharmacy. The DON also said the staff should re-order the medications 3 to 5 days before they run out. She stated LVN C was not available for interview as she had tried to contact her to come in for the in-service related to this incident. During a telephone interview with Physician A on 3/17/23 at 4:25 p.m., he stated the nursing staff called him after Resident 1 had a couple of seizures on 3/4/23 around midnight, and he gave the order to send him to the ER. He stated he was not told about the missing Keppra and became aware after he pulled the hospital ER record and Discharge Summary after the resident returned from the hospital. He stated it was really concerning and that was the reason why he spoke with the DON regarding the missing medications. He stated he expected the nursing staff to call him when they did not have the Keppra. When asked if the seizure was brought on by the missing Keppra, Physician A said, Yes. He further explained that he had been working with Resident 1's neurologist (doctor who specializes in disorders that affect the brain, spinal cord, and nerves) to reduce the Dilantin due to his increased liver enzymes (a potential side effect of Dilantin); the goal was to decrease the Dilantin if his seizure could be well controlled by Keppra. He continued to explain that at first when he was called about the seizures, he thought it was due to the low Dilantin level, not until he reviewed the hospital's records, he realized it was due to the missing Keppra. When asked whether this incident could be life-threatening, Physician A responded, Any seizure is life-threatening for sure. During another interview with the DON on 3/20/23 at 9:45 a.m., she stated the expectation was for the nursing staff to call the doctor when a medication was not available. She stated it was not addressed in policy and procedures, but it is a known thing and expected that the nurse to call the doctor for missing medications or when a resident refuses medication. A review of Resident 1's Care Plan for seizure, dated 8/24/22, indicated the goal was for the resident to be/remain free of seizure activity through the review date, and to [g]ive medications as ordered. 2. A review of Resident 2's clinical record indicated she was admitted to the facility with diagnoses including muscle weakness and epilepsy. Her 1/25/23 MDS reflected she had a BIMS score of 13, indicating she had intact cognition. Resident 2's clinical record indicated a physician's order, dated 4/13/22, for Keppra Tablet 500 mg, give 1 tablet by mouth two times a day related to epilepsy. It was scheduled to be given daily at 9 a.m. and 5 p.m. A review of Resident 2's March 2023 MAR indicated LVN D entered a code 10 for the administration entry on 3/6/23 at 5 p.m. A review of the corresponding nursing progress notes, dated 3/6/23 at 5:54 p.m., indicated: Keppra Tablet 500 mg . on order. During an interview with Resident 2 on 3/20/23 at 1:55 p.m., she stated she recalled the nursing staff having told her they did not have the Keppra to give her a couple of times within the past couple of months but did not recall the exact dates. During an interview with LVN D on 3/20/23 at 3:21 p.m., she stated, The number 10 on the MAR meant we ran out of the medication. Someone ordered it. I didn't call the pharmacy [to follow up]. She also stated she did not inform the doctor when she ran out of the medication to give and confirmed she should have informed and asked the doctor for advice as the medication was for controlling the resident's seizure. A review of Resident 2's Care Plan for seizure, dated 8/23/22, indicated the goal was for the resident to remain free of seizure activity through the review date, and to [g]ive medications as ordered. A review of the facility's policy & procedures (P&P) titled Administering Medications, dated April 2019, it indicated, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame. A review of the facility's P&P titled MEDICATION ORDERING AND RECEIVING FROM PHARMACY, dated April 2008, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis . Reorder medication five days in advance of need to assure an adequate supply is on hand. Based on interview and record review, the facility failed to provide routine medications to meet the needs of residents for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 did not receive his Keppra (generic name: levetiracetam, a medication to treat seizure disorder [a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness]) for 48 hours due to the medication not being available. The nursing staff did not notify the physician when the medication was not available to give, nor did they follow up with the pharmacy to receive the medication timely. The failure resulted in Resident 1 experiencing multiple episodes of seizures, became unresponsive while being transferred to Emergency Department (ED), and was hospitalized for treatment. 2. Resident 2 did not receive her Keppra due to medication not available x 1 dose. This failure placed Resident 2 at risk to experience seizures, falls, and injuries related to seizures. Findings: According to an online publication titled Missed Medicines as a Seizure Trigger by the Epilepsy Foundation, it indicated, Missing doses of seizure medicine is the most common cause of breakthrough seizures. Missed medicines can trigger seizures in people with both well-controlled and poorly controlled epilepsy. Seizures can happen more often than normal, be more intense or develop into long seizures called status epilepticus. Status epilepticus is a medical emergency and can lead to death if the seizures aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels. (https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines; accessed 3/22/23) 1. On 3/17/23, a review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including multiple sclerosis (a disabling disease of the brain and spinal cord where immune system attacks the protective sheath [myelin] that covers nerve fibers and causes communication problems between your brain and the rest of your body), muscle weakness, abnormality of gait and mobility, and epilepsy (also called seizure disorder). A review of Resident 1's Minimum Data Set (MDS, a care area assessment and screening tool), dated 2/1/23, indicated he had a BIMS score of 12 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated his cognitive condition was moderately impaired. Further review of Resident 1's clinical record indicated a physician's order, dated 7/28/22, for Keppra 500 milligrams (mg, unit of measurement), Give 1,000 mg by mouth two times daily for seizures. The facility scheduled it to be given daily at 9 a.m. and 5 p.m. Resident 1 was also receiving Dilantin (anti-seizure medication) 100 mg, 2 capsules in the morning and 2 capsules in the evening, starting 1/29/23. A review of Resident 1's March 2023 medication administration record (MAR) indicated Keppra tablets were not administered for 48 hours, on 3/3/23 at 9 a.m. and 5 p.m. and 3/4/23 at 9 a.m. and 5 p.m., as follows: a. On 3/3/23: 9 a.m. entry: Code 10 entered by registered nurse (RN) A; 5 p.m. entry: Code 10 entered by RN B b. On 3/4/23: 9 a.m. entry: Code 10 entered by licensed vocational nurse (LVN) C; 5 p.m. entry: Code 10 entered by RN B The MAR's Chart Code indicated each number code had a different meaning, such as 1 = resident refused, 2 = resident not available. The 10 code meant Other (specify). A review of the corresponding nursing progress notes indicated the following: a. 3/3/23 at 9:21 a.m., RN A wrote Keppra Tablet 500 mg .[dosing and frequency] . on order b. 3/3/23 at 4:17 p.m., RN B wrote: Keppra Tablet 500 mg . on order c. 3/4/23 at 10 a.m., LVN C wrote: Keppra Tablet 500 mg . on order d. 3/4/23 at 4:28 p.m., RN B wrote: Keppra Tablet 500 mg . on order Further review of Resident 1's clinical record indicated the nursing progress notes, documented by RN B on 3/5/23 at 2:20 a.m., indicating: 3/4/23 at 2330, Resident started having seizures 5x [meaning 5 times] lasting more than 3 minutes. Turned resident on his side to avoid aspiration [accidental breathing in of food or fluid into the lungs]. VS [vital signs] taken. Afebrile [not feverish]. MD [physician] notified with order to send to ER [emergency room ] for further eval[uation] . A review of the 3/5/23 Emergency Medical Services (EMS) Prehospital Care Report w/o [without] Attachments, provided by the hospital, indicated: Responded to seizures. Upon arrival pt [patient] found lying left lateral position . postictal [period of time immediately following a seizure] . Per staff pt has been witnessed to have multiple seizures starting at approx. 23:45 tonight. Per staff pt has a history of seizures . Pt is noted to have shaking of extremities and pt reports impending seizure. Pt is noted to have a full-body generalized seizure lasting approx. 2 minutes. Pt administered 2.5 mg Versed [medication to treat seizures] IM [intramuscularly, meaning deep muscle injection] . Pt is noted to be unresponsive . During transport pt remained altered and unstable. At hospital pt moved to Emergency Department . A review of the acute care hospital's History and Physical (document that provides concise information about a patient's history and exam findings at the time of admission), date of service 3/5/23 at 4:55 a.m., indicated the hospital received Resident 1 for Chief Complaint of seizure. Under History of Present Illness (HPI), a hospital's physician wrote, [Age of resident] year-old male, institutionalized due to multiple sclerosis, presents with seizures. He has a longstanding seizure disorder for which he takes Dilantin and Keppra. The patient had 2 seizures in the nursing home for which 911 was called. He seized again for paramedics and they gave him intramuscular Versed at least twice. Seizure. When the patient got to the emergency room . However he was postictal and unresponsive. Dilantin level was subtherapeutic [lower than normal range] and it turns out the nursing home ran out of Keppra 48 hours ago. Under Plan, the H&P indicated, [Age] year-old male . presents with seizures 48 hours after running out of his Keppra, also with a subtherapeutic Dilantin level. He will be admitted to [Name of Hospital] for loading of Dilantin and Keppra and resumption of both medications orally . A review of the ED Physician Documentation, dated 3/5/23, indicated Resident 1 arrived on 3/5/23 at 1:06 a.m. via EMS. The ED physician wrote, on 3/5/23 at 1:11 a.m., The patient presents with 'More seizures' tonight per nursing home staff . He was found postictal by EMS and then said he felt like he was when have a seizure and had a full-blown seizure with O2 [oxygen] as low as 75% [normal: 95% - 100%] at the end. Was given 2.5 mg of Versed . and 3/5 4:00 [a.m.] Awaiting: History from the nursing home is helpful . it turns out they have not had Keppra since the 2nd so the patient has missed 48 hours of Keppra. They do not have any still. This is clearly at least contributing to why he is seizing. I will have to admit him since I can send him back to place the does not have the medicine to care for him. A review of the ED Nurse Documentation, dated 3/5/23 at 3:58 a.m., indicated: Contacted Watsonville Nursing Center, spoke with [name of nurse] . It was also reported to this RN by [name of nurse] that the patient has not had any of his scheduled Keppra doses (patient is prescribed 1000mg Keppra BID [meaning twice daily] for seizure prevention), reported to RN that the last dose patient received was 3/2/23 evening, and has not had any dosed since then. It was reported that the facility had ran out and they were waiting for the pharmacy to deliver more . Resident 1's clinical record indicated the resident was admitted to the hospital on 3/5/23 at 4:30 a.m., and discharged on [DATE] at 10:45 a.m. The nursing progress notes, dated 3/6/23, indicated he was readmitted to the facility on [DATE] at approximately 2:50 p.m. A review of the hospital's Discharge Summary, dated 3/6/23, indicated the following under Final Diagnoses: Epileptic seizure related to external causes, not intractable [untreatable], without status epilepticus [prolonged seizure lasting longer than 5 minutes or when seizures occur close together and the person doesn't recover between seizures] . Uses less medication than prescribed . Patient's unintentional underdosing of medication regimen. The History Course in the Discharge Summary indicated, .male with multiple sclerosis . Apparently they ran out of his seizure medications at the nursing facility. Seizures. Patient was admitted and received a loading dose [large dose of a medicine used to ensure a quick therapeutic response] of Dilantin and Keppra. By hospital day 2. The patient was alert and oriented and mentating at baseline. A review of the Medical Provider progress notes, written by Resident 1's attending physician (Physician A) on 3/7/23 at 9:56 p.m., indicated: Seizure d/o [disorder] . Unfortunately was out of Keppra x 2 days and had recurrent seizures. hospitalized and dilantin dose increased again. Discussed care with DON [director of nursing] re: missed medications . For now continue current doses of Dilantin and Keppra, may try to reduce Dilantin again in future. During an interview with Resident 1 on 3/17/23 at 1:27 p.m., Resident 1 stated he had been on Dilantin and Keppra for many months for seizure disorder. He stated the day he had the seizures he was very confused and did not know what was going on. He stated prior to that the nursing staff had told him they ran out of Keppra and were waiting for the pharmacy to deliver. He stated he told them he needed the medication, but they said they were still waiting for it to come. He stated he was not aware of what went on when he was at the hospital, but they put him back on the medications and sent him back. Resident 1 stated he was aware he had the seizures because he was missing a few days of Keppra. During an interview with RN A on 3/17/23 at 2:01 p.m., she confirmed she was the morning shift nurse on 3/3/23 and coded a 10 on the MAR for Resident 1's Keppra administration. She stated Code 10 meant the medication was not available, and she ordered it through the facility's computerized system. She stated she informed Resident 1 the medication was not available. She continued, I knew he had gotten it the day prior; he was stable, they didn't have the med. RN A stated she was not aware the medication was available in the facility's automatic dispensing cabinet (ADC, an automated machine where medications are stored and electronically tracked) so she could get it from there and did not inform the doctor. She confirmed she should have informed the doctor when Keppra was not available to give to the resident. RN A confirmed she was aware Resident 1 was hospitalized for seizures due to missing his Keppra when she was counseled by the DON on 3/10/23. On 3/17/23 at 2:16 p.m., the DON provided an inventory list of medications available in the facility's ADC. The list indicated the ADC contained 115 different medications including levetiracetam (Keppra) 250 mg tablets. During a telephone interview with the Pharmacist on 3/17/23 at 2:18 p.m., she stated the facility staff requested a refill for Keppra on 3/3/23 at 9:21 a.m. (this is consistent with the interview with RN A above) but it was not delivered until 3/5/23 at 4:13 p.m. (2 days later). She stated most of the refill requests were processed and delivered from a sister pharmacy in southern California, that was why it took two days to deliver. She stated, We ask [facilities] for a few days to process refills. If they need medications urgently, they give us a call to [name of pharmacy] to send with the next run. The Pharmacist reviewed the pharmacy dispensing records and stated a 30-day supply of Keppra was delivered on 1/3/23 and on 3/5/23; there were no request for and delivery in February 2023. During a concurrent interview and record review with RN B on 3/17/23 at 3:09 p.m., she stated she coded a 10 on the Keppra 5 p.m. administrations on 3/3 and 3/4/23. When asked what Code 10 meant, RN B stated, I think that was when we ran out of Keppra. She stated, I was not able to call the doctor on those days the medication was not available and could not recall whether she called the pharmacy to follow up. She stated she informed Resident 1 that they were waiting for[TRUNCATED]